The Power of 100 Online Donation Form

Times Change the Power of 100 Donation Form

Please note: You must fill in all fields marked with an asterisk (* ).

Date:   ^*

My contact information:

Name: ^*

Street/Apt#: ^*

City:    ^*  Province: ON AB BC MB NB NL NT NS NU PE QC SK YT Outside CA ^*   Postal Code: ^*

Telephone (home):         ^*

Telephone (business):      Ext.:

Email:  ^*
(note: an invalid email address may prevent your information from being sent to us.)

My donation: I would like to make a donation of:

$100.00

Other Amount:

Dedications and Gift Options:

No

Yes, as a gift in memory of  

Yes, as a gift in honour/on behalf of  

Other:

Your Message: (Let us know why you chose the Power of 100)

Donations over $10 are tax-deductible. You will receive a charitable receipt by mail.