Health Care Foundation

A Roots Tree Donation - Step 1 of 3

First name:
Last name:
Address:
City:
Province:
Postal code:
Country:
Telephone:
Email:
Donation amount:
Relationship to Child:
Child Name:
Child date of birth (January 1, 2011):
I/We agree to have a leaf engraved with my baby's name and date of birth placed on the Health Care Foundation's Roots Tree.
I/We agree to have my baby's name placed on the Roots Tree section of the Health Care Foundation's website.
Parent information
Parent Name:
Parent Address:
Parent City:
Parent Province:
Parent Postal Code:
Parent country:
Parent Telephone:

Donation Amount: $100.00.

*When donating, all funds are in Canadian Currency.