Please Donate

Please provide your contact and payment information below. Your contact information is required to generate an electronic tax receipt which will be sent to the email address that you provide.
* denotes required information

Please make cheques payable to: Rally for Vita

Contact Information
First Name:
Last Name:
*Email:
Company:
*Address:
*City:
*Province:
*Postal Code:
Phone:
Cell Phone:

Payment Information
*Donation Amount:
*Currency:
*Credit Card Type:
*Credit Card Number
(numbers only, no dashes nor spaces):
*Card Security Number:
*Cardholder's Name:
*Credit Card Expiration: -


Please click here to download and print the registration form. Once completed, return the form either by fax or mail to us.
(To open this form, you will need Adobe Acrobat Reader)