Donation and Sponsorship Contributions

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Name*
 Agency
Street *

 City*
Postal Code / Zip Code*
 Province:*
E-mail Address*
 Telephone Number
  Fax Number
Hole Sponsorship:



Other:
Prize Donation(s): Item:

Item:
Other Cash Donation: Amount:
Tax Receipt required?

Brain Injury Community Re-entry (Niagara) Inc.
261 Martindale Road, Units 12 & 13
St. Catharines, Ontario
L2W 1A1

Telephone: 905-687-6788
Toll Free: 1-800-996-8796
Fax: 905-641-2785
Email: staff@bicr.org

BICR's charitable registration number is
13388 9378 RR0001