Donation

1 Donation Details

2 Personal Details

3 Payment Details

• With the generosity of the community and our supporters, we are striving towards the best care possible for patients at The Prince of Wales Hospital. Thank you for choosing to support us!

• Regular Givers are the life blood of our Foundation

  Monthly giving is the most valuable way you can support the work we do. It is a commitment to donate an amount of your choice each month to the Prince of Wales Hospital Foundation. It is one of the most effective ways you can support the work we do and is convenient and easy to get started.

  Regular donations are debited from your credit card or bank account automatically on the 15th of every month, with a receipt for the total annual contribution issued at the end of each financial year.

  Please click 'next' to set-up Regular Giving from your credit card.

  If you wish to make the payment via Direct Debit from you bank account please download and read our Direct Debit Service Agreement.

  Direct Debit Service Agreement

  If you are happy to have your donations debited from your bank account, please download and complete this form and return it to us. No further action is required on this electronic form if you choose this option.

  Direct Debit Request

• I want my donation to go towards:*
  Tax Appeal - Caring for Every PatientWherever my gift will help mostI am a Grateful PatientSupporting the work of Dr Koroush HaghighiSupporting the work of Dr Jason Wenderoth and the Neurointervention and Stroke ServiceSupporting the work of the Anaesthetic DepartmentI want to give monthlyIn memory of a loved oneIn celebration of a loved oneOther
• If your donation is selected as other please let us know how you would like this to be directed.*
• If the donation is in memory of a loved one please name the loved one*
• Would you like to dedicate this to a Department? If not leave blank.
• If the donation is for a special occasion please tell us what it is*
• Would you like to dedicate this to a Department? If not leave blank.
• Would you like to dedicate this to a Department or staff member?

• Your Details

  Please enter your contact details below

• Email Address (your receipt will be sent to this address)*
  Enter Email Confirm Email
• Telephone/Mobile*
• Title*
  Mr & MrsMrMsMrsMissDrSirProf
• First Name*
• Surname*
• Date of Birth
• or Year of Birth
• This will help us to understand areas that might interest you.
• Please Issue a Receipt
  • In my name
  • In my Organisation/Company name
• Company name (if applicable)
• Company position (if applicable)
• Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country
• Telephone (work)
• How did you hear about us?*
  Please choose oneII've bought raffle/lottery ticketsWord of mouthWeb search (Google etc)Fundraising websiteNewspaperRadioTelevisionMailoutOther
• If you are an existing supporter please tell us how you support POWHF*
• If Other above please let us know how you heard about us.*
• Would you like to add a personal note to your donation?
  If you would like to thank a specific staff member or department

• With your donation of $83 you can sponsor a therapeutic workshop for spinal patients within the rehabilitation ward, that helps build patient wellbeing and reduces any isolation

  Please fill out your payment details below

• I would like to make a donation of*
  AU$55.00AU$83.00AU$104.00AU$125.00AU$250.00Other
• If other please nominate the amount
• Credit Card
  American Express

  MasterCard

  Visa

  Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date   Security Code Cardholder Name
• Email
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