Dedicate a sunflower in the name of your loved one urn Rossend Help us t ale yellow ! SUNFLOWER MEMORIES ‘A lovely way to remember your loved one’ During the month of May your personalised sunflower will be displayed on lamp posts throughout Rossendale. Dedicate a sunflower for a £10 donation, please visit www.rossendalehospice.org/sunflower or complete and return the form overleaf SUNFLOWER MEMORIES Dedication form YOUR DETAILS Full name: (Mr/Mrs/Miss/Ms): ...................................................................................................... Address:........................................................................................................................................ ...................................................................................................... Post Code: ............................. Telephone: ....................................................... Mobile: ............................................................... Email: ............................................................................................................................................ LOCATION OF SUNFLOWER Sunflowers will be placed on lamp posts in areas around Rossendale. We will do our best to accommodate your request. Please tick your preferred area. Whitworth Stacksteads Waterfoot Rawtenstall Edenfield Stubbins Haslingden Newchurch Bacup Crawshawbooth Helmshore YOUR DEDICATION I would like to dedicate a sunflower to: PLEASE PRINT NAMES CLEARLY - ONE NAME PER SUNFLOWER ONLY 1. Forename:................................................... Surname:............................................................... 2. Forename:................................................... Surname:............................................................... 3. Forename:................................................... Surname:............................................................... 4. Forename:................................................... Surname:............................................................... YOUR DONATION Please make cheques payable to I enclose a donation of £ ....................... (suggested donation £10 per sunflower) Rossendale Hospice Boost your donation by 25% through Gift Aid (25p for every £1 you donate ) Please Gift Aid my donations. I want to Gift Aid this donation and any donations I make in the future or have made in the past 4 years. I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference. If you wish to donate by debit/credit card please complete your details below: Name on Card: .................................................... Card No. Start Date: Expiry Date: Issue No. Donation Amount: £ CVV No. Rossendale Hospice would like to keep you updated with monthly news, events and offers. If you would like to hear from us in the future, please tell us all ways in which you Lets keep are happy to be contacted by ticking the relevant boxes below: in touch! POST EMAIL TELEPHONE SMS Please complete and return to: Rossendale Hospice, 161 Bacup Road, Rawtenstall, Rossendale, BB4 7PL .