Women with Heart & CSUQ Shavuot Unity Evening

Full Name / Nom*
First Name Last Name
E-mail / Courriel*
Birth Date / Date de Naissance*

Month Day Year
Phone Number / Numéro de Téléphone**
Ticket / Billet*

$36
I would like to volunteer on Thursday, May 21 to distribute the flower bouquets and Shabbat bags to patients / J’aimerais faire du bénévolat le jeudi 21 mai afin de distribuer les bouquets de fleurs et les sacs de Chabbat aux patients.
What time?

Between 11-1pmBetween 1-3pm
I would like to support this program (tax receiptable) / J’aimerais soutenir ce programme (reçu fiscal disponible)*

YesNo
Amount / Montant

$36$72$180$360
Total

$0.00

Payment / Paiement*

Credit Card

We accept Visa, MasterCard, American Express
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

I hereby grant permission for photographs or videos to be used for promotional materials, including flyers, websites, and social media platforms.

J’autorise l’utilisation de photos ou vidéos à des fins promotionnelles, incluant les affiches, le site web et les réseaux sociaux.
Yes / OuiNo / Non
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