Updates

I hereby authorize Heart to Heart Children's Home in Haiti Society to initiate monthly electronic debits for the financial institution specified by me to pay from my chequing or savings account, the amount indicated as follows:

Date commencing: *

I would like this debit from my account on the: *

1st of every month
15th of every month

How many children would you like to sponsor?

How many classroom(s) would you like to sponsor?

How many teacher(s) would you like to sponsor?

Amount to be debited per month

Sponsorship is $35.00 per month for one child, one classroom, or one teacher.

RECONSTRUCTION SPONSORSHIP

I would like to help with the reconstruction of:

The School

The Kitchen

Amount to be debited for reconstruction per month

For how many months?

CONTACT INFORMATION

This authority to remain in effect until revoked by me in writing. I understand that both Heart to Heart Children's Home and my financial institution reserve the right to terminate this payment plan or my participation therein.

First Name

Last Name

Email

Address

City

Zip / Post Code

Phone

Today's Date

VOID CHEQUE UPLOAD

To ensure accuracy, please attach a specimen cheque marked "VOID"*