Commemorative Donation Form

Yes, I want to create a lasting memory with a commemorative gift and purchase my plaque today.

If you have questions please contact Hannah May, Development Officer, Leadership Giving at 416-294-2362 or hannah.may@uhn.ca.

Field Is Required Choose your plaque size:

$2,500.00

4"x4" plaque

$5,000.00

5"x5" plaque

$10,000.00

5"x7" plaque

$25,000.00

5"x10" plaque

Personalize your plaque

Provide the message/name you would like to show on the plaque. Only letters, numbers, and simple characters are allowed (example: "Loving Memory of John Smith").

Your inscription: 1 line - 30 characters

Your inscription:

Additional Information

Choose your dedication:

Name of honouree(s):

If in memory, please provide the year of birth and the year of passing:

Year of birth:

Year of passing:

Please reserve my plaque at:

Donor information

This is a company gift

Company name:

Title:

First name:

Last name:

Position:

Street 1:

Street 2:

City:

Province/State:

Country:

Postal code/ZIP:

Email address:

Home phone number:

Cell phone number:

If you donate and have not already registered, you will receive periodic updates and communications from UHN Foundation.

Please make this gift anonymous. Please make this gift anonymous.

Please send me information about leaving a gift in my Will.

I have included UHN Foundation in my Will.

Payment information

Credit Card Information:

Credit card type:

Card number:

Expiration date:Select month of credit card Select Expiration Year

CVV number: What is this?