Donate today to help us do more for children at St Mary's.

I'd like to help provide extra support for children and families by making a donation to the St Mary's Children's Fund:

£100 £50 £25

My chosen amount of £

I would like to pay by:

Your details

Title

First name

Address cheque (enclosed with this donation form)

Mastercard/Visa (delete as appropriate)

Please contact me about my donation

Surname Postcode

Phone number

Email

Payment details

Name on card

Card number

Expiry date /

Gift Aid

For every £1 you donate, Gift Aid allows us to claim 25p from HM Revenue & Customs, increasing the value of your donation at no extra cost to you. Please tick the box below:

Yes, I would like Imperial Health Charity to claim Gift Aid on any donations I make in the future or have made in the past four years. I am a UK taxpayer and I understand that if I pay less Income Tax and/or Capital Gains Tax in the current tax year than the amount of Gift Aid claimed on all my donations it is my responsibility to pay any difference.

Signature Date

Yes, I would like to hear from Imperial Health Charity about the impact my gift has made as well as other news, events and opportunities to support their work. (You can opt out of communications at any time by emailing fundraising@imperialcharity.org.uk. For more information, go to imperialcharity.org.uk/privacy)

Please make sure all the fields above are completed and return this form to:

St Mary's Children's Fund, Imperial Health Charity, 178-180 Edgware Road, London, W2 2DS

St Mary's Children's Fund is a special fund managed by Imperial Health Charity to support children's services at Imperial College Healthcare NHS Trust.

A registered charity, no. 1166084