Donation Purpose *
select
 
Description
Donation Item *  
Item Description
Name *  
Address *  
City/St/Zip *    
select
     
Email Address *
Contact Phone *
Notes/Comments
Total Due:
Payment Comments
First Name on Card      Last Name    
Card Billing Address
City/St/Zip    
select
     
Card Number  (NO spaces,dashes)
Expiration Month/Year
select
  
select
Security Code  
 
   
 

We hope you find it easy to get information and to register for our programs. If you have any questions, comments, or need assistance, call 860-873-5058 or go to our website at www.easthaddamrec.com for further information.