DEMENTIA SA PLEDGE/DONATION FORM
REGISTRATION: 049-191NPO; PBO-930022142
B-BBEE CONTRIBUTOR: LEVEL 4 (>65 but <75)
B-BBEE PROCUREMENT RECOGNITION LEVEL: 100%
Yes!!
I/We would like to support Dementia SA
PLEASE TICK RELEVANT BOX:
COMPANY
INDIVIDUAL
FOUNDATION
AGENCY TRUST OR ESTATE
OTHER S AFRICA
INTERNATIONAL
IF YOU WOULD LIKE TO CLAIM A TAX DEDUCTION FOR YOUR DONATION & RECEIVE A SECTION 18A TAX RECEIPT, PLEASE ENSURE THAT
YOUR FULL CONTACT DETAILS ARE SUBMITTED ALONG WITH YOUR DONATION TO DEMENTIA SA.
NAME
:
TITLE
:
INITIALS
SURNAME
:
:
ADDRESS :
TELEPHONE NO:
POSTAL CODE
:
DEMENTIA SA: PROGRAMME OPTIONS (please tick options) CHOOSE WHERE YOU WANT TO MAKE YOUR INVESTMENT IN DEMENTIA
CARE & SUPPORT:
Family Support Groups
Public Awareness material & information
Family Counselling
Advocacy Development
Help Line service
Partnership Development
Education & Training
All Dementia SA services
TAX OPTION:
BEQUEST OPTION:
CASH
GOODS
SECTION 18A TAX RECEIPT – PLEASE INDICATE IF YOU REQUIRE A SECTION 18A TAX RECEIPT.
I MAY WANT TO LEAVE A BEQUEST. PLEASE LET ME HAVE MORE INFORMATION.
SERVICE
PAYMENT METHOD OPTIONS:

CHEQUE/POSTAL ORDER FOR
Please cross & make payable to
Dementia SA


BY DATE:
R
R
OR
DEBIT/CREDIT CARD
ACCOUNT NO
(incl last 3 digits on
Back of credit card)
EXPIRY DATE:
BANK:
BRANCH:
WITH THE AMOUNT OF:
SIGNATURE:
R
OR

DEBIT ORDER INSTRUCTION:
I wish to donate R
Monthly / Annually from my Account.
Account No:
Bank:
THE FIRST DEBIT ORDER IS TO COMMENCE ON
DIRECT TRANSFER INTO DEMENTIA SA BANKING ACC:
BANK:
FIRST NATIONAL BANK
BRANCH CODE: 201409
ACCOUNT TYPE: CHEQUE
ACCOUNT NO:
62103751196
ACCOUNT NAME: DEMENTIA SA
to be deducted
Branch:
SIGNATURE:
OR
CONTACT INFORMATION:
TELEPHONE NO:
(021) 4210077/78
FAX NO:
(021) 4182772
E-MAIL:
accounts@dementiasa.org
WEB SITE:
www.dementiasa.org
POSTAL ADDRESS: P O Box 16421 Vlaeberg 8018
CARING FOR YOUR FAMILY IS YOUR FIRST PRIORITY; CARING FOR YOUR COMMUNITY IS YOUR PRIORITY CHOICE
There is not a joy the world can give like that it takes away – Lord Byron
Dementia and Alzheimer’s disease rob many parents and grandparents of a life once lived; threatening
the quality of what life is left. Gone, are the corner stones of one’s existence - knowing who you are, where
you’ve been and whom you love!
Alzheimer’s disease takes away one’s past and debilitates one’s future. There can be few mental diseases
as hideously cruel, leaving in its wake the heartbreak of loss; total dependency and exposure to abuse and
neglect; stigmatization; emotional and financial trauma.
We cannot restore people’s memories and repair their damaged minds. We cannot re-unite a husband
with the wife he loved; or make a mother remember the son she gave birth to; or help a grandmother
recognize the grandchildren she read to.
But we can, with your help, provide people with dementia and their families the care and understanding
they desperately need. We can, with your help, restore their dignity and provide a better quality of life.
Help us catch these ageing souls, who are falling from everything they knew, from everyone they’ve loved.
Support
Groups
By giving
them and their families YOUR support through the services that we provide.
Support groups which meet monthly for family & care- givers of persons suffering from dementia, and networking
support groups for professionals working in the field of memory care and facilities offering dementia care.
Family Counselling
This service provides personal access to a counsellor (either at home or at the DSA offices) through face- to- face
consultation for support, guidance and information.
Help Line Service
Including telephonic, emailed and written requests for help and advice, is offered on a daily basis. Giving people
immediate access to a counsellor to provide support, guidance and information.
Adult Education & Training (Formal & Informal)
Various lectures, talks, courses, symposiums are offered catering for the general public (families, care-givers,
communities) and catering for professionals working in the field of dementia. This education serves to develop skills,
awareness and knowledge relating to the disease and helps with early diagnosis of patients and ensures adequate
management of the illness.
Public Awareness material & information
Various public education material is produced and awareness campaigns are organized aimed at
increasing the understanding, early detection and intervention of dementia in our community.
Advocacy
We are the only organization actively advocating the rights and dignity of those affected by dementia. Together
with other organizations we have successfully lobbied government on the Older Persons Act, which has ensured the
inclusion and recognition of dementia and people with dementia in the Act. Other areas include convincing the
Medical Aid industry to recognize Alzheimer’s disease as a chronic illness and to provide financial cover for related
costs such as medication.
Partnership Development
Dementia SA considers all partnerships to be the life-blood for any community organization. Collectively sharing
resources to effectively address the needs of those affected by dementia. Some new and exciting partners include:
the Provincial Department of Social Development, Medic Alert and ‘For Dementia’ – UK based dementia-training
specialists.
If you would prefer to make a Donations in the form of goods or services, (which is also tax deductible) please find a
list of goods/services we currently require assisting those affected by dementia.