Beaumont Hospital Foundation
Beaumont Hospital
Dublin 9.

I wish to donate money to Beaumont Hospital Foundation. I enclose a cheque /

postal order for € __________

My details are as follows:

Name: __________________________________________

Address: ________________________________________

________________________________________

Email Address: ___________________________________

Telephone (optional): ________________________

From time to time Beaumont Hospital Foundation may write to you with regard to fundraising activities..

If you do not wish to receive such information, please circle ... yes/no

Beaumont Hospital Foundation will not disclose personal information to any other parties.

Signed: ________________________________________________________