The HeArt Centre Dergah - 500 Hearts Donor Form

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- Our Vision
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500 Hearts
Expansion
Spiritual Development
CMSL Madrassa
Contact

Home
About
- Our Vision
Events
500 Hearts
Expansion
Spiritual Development
CMSL Madrassa
Contact

Join the 500 Hearts Campaign and help expand the HeArt Centre Dergah — a home of love, remembrance, and learning for all.

Please complete this form after making your donation so that we can confirm your details and include the correct name on the HeArt Wall of Donors.

💚 You may dedicate your donation in your own name or on behalf of a loved one, parent, or family — each name inscribed will remain a lasting legacy of love.

Your Full Name - Please enter your full name as the contributor (for our records only).

Email - Used for confirmation and updates.

Phone Number - In case we need to contact you regarding your donation.

Please tell us exactly how you would like the name to appear on the HeArt Wall of Donors.

Dedication Type

This donation is in my own name.
This donation is on behalf of someone else (parent, loved one, or family).
This donation is in memory of someone who has passed away.

If on behalf or in memory, please specify their name and relationship.

Please confirm your contribution so we can verify it with our NatWest records

Amount Donated (£)

Date of Donation

Payment Method

Bank Transfer
Standing Order
Other

Reference Used (if applicable)

If you are spreading your donation over time, please indicate your plan.

Donation Plan

One-Time £1,000
12 Months (£83 per month)
24 Months (£42 per month)
48 Months (£21 per month)
Other amount / duration

Other amount / duration

Consent and Acknowledgement - Please confirm the following.

I confirm that the information provided is accurate and that I have made, or will make, my donation to The Heart Centre (NatWest Bank – 60-22-47 / 66114837).
I give permission for the name(s) provided to appear on the HeArt Wall of Donors.
I understand that all information provided will be used only for donor recognition and financial verification.

The HeArt Centre Dergah, 73-75 Shaw Hill Road, Ward End, Birmingham, B8 3LJ

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