Registered Charity No: 295452

Lights of Love Dedication Form

Please print and complete this form and send it to:
Lights of Love, South Bucks Hospice,
9a Amersham Road, High Wycombe, Bucks HP13 6PN
or FAX 01494 449154

Alternatively, please hand in the dedication slip with your donation at one of our Charity shops, or The Hospice at 9a Amersham Road, High Wycombe

Full Name:

Address:

Postcode:

Telephone:

I wish to sponsor ................. Lights on the tree.

In Memory/Honour of ......................................................

............................................................................................

I enclose a cheque for £ as my donation to the Hospice

Gift Aid

Registered Charity Number 295452

Thank you for your generosity