Your Full Name (required) Your Email Address (required) Would you like to receive the bi-weekly winners email?—Please choose an option—YesNo Would you like to receive the Foundation’s e-Newsletter?—Please choose an option—YesNo Would you like to add additional names on the ticket (up to 2 additional names) 1st additional name 2nd additional name Is this ticket purchase a gift?—Please choose an option—YesNo Recipient Name Recipient Address Recipient City Recipient ProvinceOntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandQuebecSaskatchewanYukon Recipient Postal Code Recipient Telephone Recipient Email (optional)
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our Full Name (required) Your Email Address (required) Select the fund your donation will supportGeneralChild and Adolescent Mental Health Unit - Gislain's StoryGreatest Need FundCentral Fetal Monitoring SystemChild & Adolescent Mental Health UnitGreen Light LaserPoints for PaulAcute Inpatient PsychiatryCancer Care FundCardiac Care FundCritical Care FundDiagnostic Imaging FundEducation Endowment FundLong Term Care FundMaternal/Child Care FundMedical Care FundMental Health - Early Intervention in PsychosisMental Health - Psychosis InterventionRegional Mental HealthRenal Dialysis Care Fund Would you like to receive information on monthly giving?—Please choose an option—YesNo Dedicate your donation—Please choose an option—In memory ofIn honour of Dedicated to Message for the North Bay Regional Health Centre Foundation
50 College Drive, P.O. Box 2500 North Bay, ON P1B 5A4 Tel: 705-474-8600
680 Kirkwood Drive, Sudbury, ON P3E 1X3 Tel: 705-675-9193 Fax: 705-675-6817
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Visitors Guide