I wish to be a member of the Dundas County Hospice
New Member              Renewal              I enclose my $10.00 membership fee

I wish to make a further donation at this time: $_______________
(income tax receipts will be issued)

Name: _______________________________

Address: _________________________________________________________

               __________________________________________________________

Signature: ______________________________________

mail this form to:
The Dundas County Hospice, Box 228, Park Drive Villa, Williamsburg, Ont. KOC 2HO