download our order form - Pilgrims Hospices

Payment Details
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First name
Surname
Address
Telephone
Email
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Calculate your payment
Please indicate below how many bricks you would like to order:
Single Brick Qty @ £50 each £
Double Brick Qty @ £100 each £
Total Order Amount
Terms and Conditions:
Pilgrims Hospices will have complete control over
the location and date of installation of all bricks in
the Pilgrims Path .Thereafter the bricks will remain
the property of Pilgrims Hospices. Pilgrims Hospices
agrees to maintain the bricks for a minimum of
10 years. Bricks may become worn, weathered or
damaged by natural causes without any liability
to Pilgrims Hospices. In exceptional circumstances
Pilgrims Hospices reserve the right to relocate the
bricks. Pilgrims Hospices reserves the right to refuse
any application where the inscription is other than a
name. Any amendments to the inscription provided
on the order form must be notified within 7 days of
receiving the Certificate. Thereafter, Pilgrims Hospices
will not be able to make changes to inscriptions.
On receipt of your order form, your request will be
subject to (a) approval of it by us (b) availability of the
brick and(c) remaining space in the Path. Once your
request has been accepted, we will begin processing
your payment and send out your certificate.
Data Protection: Pilgrims Hospice 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 prefer not to receive information please
tick the box:
(minimum donation)
(minimum donation)
£
Pilgrims Hospices is a
charity providing specialist
palliative care free of charge
to people in east Kent.
We care for people with illnesses that
cannot be cured including cancer,
heart failure, respiratory conditions and
neurological diseases. Care is provided
from the three sites in Canterbury,
Ashford and Thanet, in patients’ homes
and via community programmes and is
also extended to families and carers.
To keep delivering these services to
those that need it the most, Pilgrims has
to raise nearly £9 million each year. The
majority of this comes from our local
community so your support is vital to
our fundraising efforts. Here is an idea of
where the money you help us raise goes.
£50 can support bereaved children’s days
£200 enables a visit to a patient’s home
from one of our community nurses
£475 could provide nursing care
for a week
£500 24 hours care for an in-patient
£3,000 The cost of a pressure
relieving mattress
Pilgrims Paths
Create a lasting memory in a Pilgrims Path
Payment
I enclose a cheque for £____________________ made payable to: Pilgrims Hospices
Debit/credit card: I hereby instruct you to debit my: Visa / Mastercard / Maestro account (please circle)
Valid From
Did you know that if you are a UK tax payer, we can increase your
donation by an extra 25% under the Gift Aid scheme making your
donation go further at no extra cost to you If you would like to help
us in this way just tick the box then sign and date below.
I am a UK tax payer and would like Pilgrims Hospices to treat this donation and all future
donations I make hereafter as Gift Aid donations. I understand that I must have paid
an amount of income or capital gains tax at least equal to
the amount Pilgrims Hospices in East Kent will claim from
the Government on my donation.
Date:
Expiry
Security No.
Ann Robertson OBE, founder of Pilgrims Hospices:
“
This is a lovely way of supporting your
Pilgrims Hospice. At the entrance of
each of the Hospices there are plaques
on the walls saying ‘Built by the people
of East Kent, for the people of East
Kent’. Helping us to build a Pilgrims
Path will be a true testament to this.
”
Signature: _______________________________________
Please return this form and your payment to:
Pilgrims Paths, 56 London Road, Canterbury, Kent CT2 8JA
Date: ________________________________
Pilgrims Hospices in East Kent is a company limited by guarantee.
Registered charity number 293968.
Registered company number 2000560.
Registered office 56 London Road, Canterbury, Kent, CT2 8JA.
www.pilgrimshospices.org

Create a lasting memory in a Pilgrims Path...
Order Form
To be part of Pilgrims Paths, please complete the form below. If you would like
more than two bricks, please use another form (photocopies are fine).
Pilgrims Hospices gardens
have long provided peaceful
havens for patients, families,
friends and visitors.
The creation of memorial paths
within these gardens offers the
opportunity of creating a lasting
memory of a loved one that can
be revisited for years to come.
You are invited to help create these
paths, which will be built at all three
hospices in Ashford, Canterbury and
Thanet starting in Spring 2012, by
sponsoring a brick engraved with
the name of a loved one.
By adding to the Pilgrims Paths you
will also be contributing to the future
of the hospices. The funds raised
will go directly to supporting and
developing the services and care we
give both in the hospices and homes
of people in the local community.
How it works
Pre-order your special brick
and tell us the name you would
like engraved.
Your Pilgrims brick will be engraved
with the name of your loved one,
group or company. We can only include
names, no dates or messages please.
Get your certificate
Once we receive your order form
you’ll be sent a certificate to confirm
the wording of your inscription.
Please check this immediately
and let us know within seven
days if you would like to
change anything.
Single brick £50.00
(210mm x 105mm x 50mm)
Gold Lettering
Double brick £100.00
(210mm x 210mm x 50mm)
Gold Lettering
I would like a brick placed in; (please tick a box below)
Pilgrims Path
Ashford
What name would you like on your brick
Please write the name that you would like engraved in the boxes below. You can
use up to 15 characters per line. Please leave a blank space between each word.
Example:
P i l g r i m s
H o s p i c e s
C h o s e n N a m e
Please enter your text below:
First Brick:
Single Brick
Double Brick
Pilgrims Path
Thanet
Pilgrims Path
Canterbury
Come and see it
Once the bricks have been laid
in 2012 we’ll invite you in to come
and walk the path which holds
your very special memory.
Second Brick:
Single Brick
For further information...
call us on 01227 782066
or email pilgrimspaths@pilgrimshospices.org
or visit www.pilgrimshospices.org
Double Brick
Please turn over
to complete
your details...