Donation Form BPH-2013-4-29

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Bairo Pite Hospital – We need your support to continue to provide care
Bairo Pite Hospital sees support for the inpatient beds and the nurses as the first priorities amongst many.
Sponsor a Bed
There are 55 inpatient beds at Bairo Pite Hospital. The total cost of care for each patient in each bed is
approximately $10 per day ($300 per month). This covers medication, medical supplies, medical staff,
pathology, utilities, food and laundry.
Please tick one of the following boxes to sponsor a bed at Bairo Pite Hospital for:
□ 1 month - $ 300.00
□ 6 months - $1,800.00 □ in one donation
□ in monthly instalments of $300.00/month
□ 12 months - $3,600.00 □ in one donation
□ in monthly instalments of $300.00/month
□ Ongoing support in monthly instalments of $300/month
□ Ongoing contribution to the cost of a bed of $_________ monthly
Part of Sponsor a Bed Syndicate named:_____________________ (The name can be finalised at a later date)
For 6 months or more support the bed can be given a name by you (eg the Jones Family bed) and this
name will be placed on the wall above the bed for the duration of your support of that bed. We will contact
you to discuss naming the bed.
Sponsor a Nurse
Our Nurses work 12 hour shifts. They are paid almost exactly the same amount each month as the cost of
sponsoring a bed-$300 a month. They usually have 5 or 6 children at home and are often the sole source
of income for their family. They are dedicated and have some superb skills. They are the ones who insert
the IV cannulae and set up the IV drips. They are the ones who administer all the medications and who
ensure that the patients get the care that they need.
Please tick one of the following boxes to sponsor a nurse at Bairo Pite Hospital for:
□ 1 month - $ 300.00
□ 6 months - $1,800.00 □ in one donation
□ in monthly instalments of $300.00/month
□ 12 months - $3,600.00 □ in one donation
□ in monthly instalments of $300.00/month
□ Ongoing support in monthly instalments of $300/month
□ Ongoing contribution to the wage of a nurse of $_________ monthly
Part of Sponsor a Nurse Syndicate named:____________________ (The name can be finalised at a later date.)
If you sponsor a nurse for 3 months or longer then we will ensure that you and you sponsored nurse can
correspond so that you have a very first hand connection with the care at the Hospital.
Or a donation can be made that is not part of the Sponsor a Bed or Sponsor a Nurse program to
support any of the other major medical services delivered by the Hospital
I would like to make a donation to assist in the work of Bairo Pite Hospital of: $1,000 $500 $100 $50
$25 Other $
□ $____________ once
□ $___________ monthly until further notice
Please continue on to the next page to see how to make a donation
The Bairo Pite Hospital (BPH) - Our Partnership With AFAP
“Bairo Pite Hospital is a community partner of AFAP. AFAP and Bairo Pite Hospital work in collaboration with local communities
to deliver development initiatives in Timor-Leste. AFAP is committed to supporting effective development programs overseas
and closely monitors all the work we undertake including initiatives undertaken as part of the Community Partner Program.
Bairo Pite Hospital does not have DGR status in its own right and relies on AFAP’s DGR status endorsed by the ATO, therefore
any donations to support the activities of Bairo Pite Hospital must be made through AFAP in order to be tax deductible. Whilst
AFAP will endeavour to comply with the wishes of the donor, AFAP retains a discretion at all times whether or not to distribute
donated property(money or otherwise) in accordance with the preference expressed by the donor. AFAP allows donated
property (money or otherwise) to be used only for benevolent activities. For more information on how to donate, please contact
AFAP or Bairo Pite Hospital.”
Thank you for your donation, your support is greatly appreciated.
All donations of $2 or more are gratefully received and fully tax deductible.
Details (to appear on your tax receipt): First name: _____________ Surname: ___________________
Business / Trust / Foundation name (if applicable): ___________________________________________
Address: ________________________________________________________________
Telephone: ________________ Mobile: __________________ Email: ____________Fax: ____________
Credit Card Details: Credit card type (please circle):
Visa
Mastercard
Credit Card Number
Expiry Date: _____ CCV number (Last 3 digits on back panel): _______ Name on Credit Card:_________________
Donations by cheque: Cheques should be made out to AFAP (Bairo Pite Hospital)
Donations can be made by telephone: 1800 007 308
Donations can be made through the AFAP website: www.afap.org
For a website donation: Click on donate, then click on Donate to our Partners, select AFAP Partners which
automatically brings up a drop down menu with Bairo Pite Hospital on it
Donations can be made by faxing or posting: Fax: 02 9436 4637 Post: PO Box 12, Crows Nest, NSW, 1585
There is much more to the Bairo Pite story
In addition to the 55 in-patient beds, BPH runs an extensive out-patient consulting service
which sees between 200 and 300 people a day, a busy ante natal care unit, a labour ward where
over 100 babies per month are delivered, an outpatient supervised treatment of tuberculosis clinic,
HIV diagnosis, counselling and treatment, daily mobile clinics to outlying communities, a dental
clinic and the training of community birth attendants and village health workers.
Would you like to talk with us about other ways to support BPH (for example a corporate
sponsorship or corporate assistance relationship, pro bono services, a personal time commitment,
in kind donations/support, getting involved personally in the work of BPH)?
□Yes
What is the best way to contact you? _______________________________________
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