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Community Warmth Donation Form

Yes! I would like to make a contribution on my City of Medicine Hat Utility bill to the Community Warmth Program.

Name:

Utility account number:

Phone number:

email address:

Service address:

DONATION OPTIONS: Please add the monthly contribution amount to my City of Medicine Hat Utility bill:

$1/month

$2/month

$5/month

$10/month

Other

OR

Please add a one-time contribution amount to my City of Medicine Hat Utility bill:

I acknowledge that checking this box verifies that I agree to the amount above as a donation to the Community Warmth program.

I accept

By submitting this application/form you acknowledge and agree that any electronic signature provided by you herein is the same as a handwritten signature for the purposes of legality, validity, enforceability, and admissibility.

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Date Signed:

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Community Warmth Donation Form

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