£1 on the bill registration form

Restaurant or Pub Name(Required)

Address(Required)

Street Address Address Line 2 City County Postcode

Organisational email address(Required)

Organisation Telephone Number (please do not include spaces)(Required)

Name(Required)

First Last

Job Title(Required)

Work Email(Required)

Daytime Contact Number(Required)

What date are you planning to start adding your discretionary £1.00 on the bill?(Required)

Please tell us why you're fundraising

Please provide details

Stay in touch We may stay in touch with you by post, phone and social media with news from the hospice, information about events you might be interested in and other ways you can support terminally ill children. If you would also like to hear from us by email, please tick below.

Email Opt In

Yes, I'm happy to receive emails from Helen & Douglas House

We take your privacy seriously. For more information about what we do with your data, please read our privacy policy at www.hdh.org.uk/supporter. You can opt-out of receiving this information, or having your data used in these ways, at any time by contacting us on [email protected] or 01865 799150.

This field is hidden when viewing the form

Hidden

Facebook Advanced Matching

Facebook CAPI