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Commemorative Bench Program Form

Donor Information

First name

Last name

Address

City

Postal code

Email address

Phone number

Secondary Donor Contact

Commemorative Benches are built to last. When your bench becomes available for renewal after 10 years, adding a secondary contact can help ensure your seat is saved.

First name

Last name

Email address

Phone number

Bench dedicated to

Inscription (40 words maximum)

Preferred location

Alternate location

Donation value

Cemetery Location $3330

Premium Location $3150

Standard Location $3020

Terms and Conditions

Pursuant to s. 33 (c) of the Freedom of Information and the Protection of Privacy Act, the personal information collected on this form is for the purpose of an operating program or activity of the City of Medicine Hat. Questions regarding the collection and use of personal information can be directed to the FOIPP Head of Local Body at clerk@medicinehat.ca.

Do you agree to the above terms and conditions?

I agree

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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