A Rose to Remember order form

If you have any questions about A Rose to Remember, please call us on 01227 782066.

Your order

Select the type of A Rose to Remember order you would like to make from the dropdown box below. Please note that if you would like to select more than one option, you can make a further order after submitting this one.

Please select an option...

Donation

I would also like to make a donation of:£

Gift Aid declaration

Did you know that if you are a UK tax payer we can increase your donation by an extra 25% under the Government's Gift Aid scheme, making your donation go further at no cost to you?

I am a UK tax payer and would like Pilgrims Hospices to treat this donation and all future donations I make as Gift Aid donations. I understand that I must have paid an amount of Income Tax or Capital Gains Tax at least equal to the amount Pilgrims Hospices will claim from the Government on my donation.

Your details

Title

Your title

First name(required)

Surname(required)

Address 1(required)

Address 2

Town or city(required)

Postcode(required)

Country

State Code(required)

Email address(required)

Confirm your email address(required)

Telephone(required)

Data protection

Pilgrims Hospices is registered under the Data Protection Act. Your name and address will not be disclosed to any other organisation but we may, from time to time, send you news about Pilgrims Hospices and information about events.

If you would like to receive this information, please tick the appropriate boxes below.

I would like to receive information about Pilgrims Hospices by email

I would like to receive information about Pilgrims Hospices by post

Security information

Secured by SagePay

Be assured that your transaction will be handled safely and securely online by our payment provider SagePay.

Gift Aid

If you are a UK taxpayer, please remember to tick the Gift Aid box. This enables us to reclaim tax on your donation, increasing its value to us by 25% at no extra cost to you. Find out more about Gift Aid