Make a single donation or pay in money you have raised One Time Gift Monthly Gift Donation Amount £10£25£50Other: Processing Date: Number of Installments: Make your gift worth 25% more! If you are a UK taxpayer, Guy’s and St Thomas’ Charity can reclaim the tax on your donation and receive an extra 25p for every £1 you donate. Please only tick the box below if this is a personal donation. Money raised through an event or fundraiser cannot be Gift Aided. Yes, I would like Guy’s and St Thomas’ Charity to treat this and any donations I make in the future or have made in the past four years, as Gift Aid donations. I am a UK taxpayer and 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. Please inform us if you no longer pay sufficient UK tax, change your name or home address, or wish to cancel at any time after the date of this declaration. Donor Information Personal Donation Organisation Donation Name Title Title Dr Mr Mrs Miss Ms Mx Prof Rev Other First Name Last Name Organisation Name Contact Information Home Work Enter address manually Address 1 Address 2 Country AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CÔTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR RÉUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHÉLEMY SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE State/Province State/Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon State State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State State/Province ACT NSW NT QLD SA TAS VIC WA County City Postcode Phone Number Email Address Keeping in TouchGuy’s and St Thomas’ Charity will hold your details to process your donation and keep you up-to-date on fundraising and what’s happening at Guy’s, St Thomas’ and Evelina London Children’s Hospital. If you would prefer not to hear from us you can stop receiving further communications at any time by telephone on 020 7848 4701 or email info@supportevelina.org.uk. For information on how we will use your details please see our privacy statement.We're sure you’re aware that Data Protection laws have recently changed so we won’t be able to contact you by email or SMS unless you provide your consent. Occasionally, we may get in touch to tell you about our vital appeals which support our hospitals, amazing events like our carol concert, or challenge events and volunteering opportunities. Are you happy for us to use your contact details to let you know about fundraising, news and events by: * Email?YesNo* Text?YesNoIf you raised this money as part of an event or fundraiser, what was the name of the event / how did you raise this money? If you raised this money as part of an event or fundraiser, and you are paying in donations on behalf of team members or an organisation, please list their name(s). Payment Information Credit Card PayPal EFT Card Holder Name Card Number Expiry MM Expiry MM 01 02 03 04 05 06 07 08 09 10 11 12 Expiry YY Expiry YY 19 20 21 22 23 24 25 26 27 28 29 CVV (?) Valid from MM Valid from MM 01 02 03 04 05 06 07 08 09 10 11 12 Valid from YY Valid from YY 19 18 17 16 15 14 13 12 11 10 09 Issue Number Bank Name Bank ID Cheque Number Transit Number Account Number By continuing, you acknowledge that your credit card will be charged on a recurring basis for the duration outlined or until cancelled.