Please fill out this form and click the Continue button to donate a fixed amount of one dollar from your Genesis power bill each month.

Name	*
Address	*
Phone
Email Address
Amount of (monthly) donation	$ 1.00 $ 2.00 $ 3.00
Genesis Consumer Number	*
I agree to donate this amount monthly from my Genesis power bill *

Please note that your details will be confidential to Genesis Oncology Trust.

Although entering your email address and address is not mandatory, we would like to send a thank you note for your donation.