Trees of Healthy Wishes

In the spirit of goodwill and peace, our community is invited to help us light West Lincoln Memorial Hospital's Trees of Healthy Wishes in Grimsby, Lincoln and West Lincoln. Your donation can send holiday greetings and illuminate a tree light or an angel, making healthy wishes happen.

1. Donor Information

2. Title: *
   Dr. Mr. Mrs. Ms
3. First Name: *
4. Last Name: *
5. Organization:
6. Phone: *
7. Email: *
8. Street: *
9. Unit/Apt:
10. City: *
11. Province/State: *
12. Country: *
    Canada USA
13. Postal/Zip Code: *

14. Donation Information

15. Donation Amount:

16. Healthy Wish for Publication

    (If you do not complete this section, your name and wish will NOT be published in the newspaper.)

17. Name:
    Description: Enter name as it should appear in newspaper.
18. Your Healthy Wish:

19. Payment Information

20. Total:
    $0.00
21. Card Holder:
22. Card Number:
23. CVV/CVC:
    3-digit value located on back
24. Expiry:
    01 - January 02 - February 03 - March 04 - April 05 - May 06 - June 07 - July 08 - August 09 - September 10 - October 11 - November 12 - December 2017 2018 2019 2020 2021 2022 2023

25. Miscellaneous

26. Additional Comment(s):

27. Confidentiality

    I understand that West Lincoln Memorial Hospital Foundation Inc. will keep my donation information I provided here confidential and agree that the Foundation may forward information or requests for donations in the future.

28. Save