Region of Waterloo Form

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Region of Waterloo Museums Donation

First Name:

Middle Initial:

Last Name:

Address: (Street, Apt. No., P.O. Box, R.R. No.)

City/Town:

Province:

Postal Code:

Country:

Phone number:

Email:

Donation Amount

$10

$25

$50

$100

Other

By continuing I confirm:

i) I understand that The Regional Municipality of Waterloo operating as Region of Waterloo Museums (the "Region") retains unconditional and complete ownership of the funds donated and/or items purchased with donated funds, and that I retain no ownership in such property.

ii) I understand that the Region's staff will use their best judgment about how this donation may best be used for Cultural Services, and that I do not expect to be informed of their decision or have any control over such decision.

iii) The Region shall not be liable in any way to the donor for any damage, loss or injury of any nature whatsoever, or any costs or expenses that may be incurred because of any such damage, loss or injury, that may occur in the furtherance of the administration of the donation.

Personal information requested on this form is collected under the authority of the Municipal Act and will be used to maintain a record of the funds donated to the Department of Planning, Development and Legislative Services. Questions regarding this collection should be forwarded to the Manager, Region of Waterloo Museums, Planning, Development and Legislative Services, at 10 Huron Rd., Kitchener, ON N2P 2R7. 519-748-1914.