Regional YMCA of Western Connecticut

Please complete the following information to contribute
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Last Name:      First Name:            
Address:            City:      
State:             Zip:           
 Please keep my/our name anonymous in the Annual Report 
E-Mail Address:            
Daytime Phone #:       
Contribution/Pledge Amount:       If Other, please specify amount: 
Payment Schedule:      Over a period of:     
Effective start date one-time contribution or pledge:    Year:  
I would like to restrict my contribution/pledge to:  
My company has a matching gift program:   
Contact Name:       Contact Phone #:
Is your contribution/pledge made as a commemoration or in honor/memory of someone? Yes  
Please keep my/our name anonymous:  
If you answered "yes" to a commemoration, please complete the following, as applicable:
Last Name:      First Name:      
Address:     City:
State:              Zip:           
Please include the following greeting: 

Authority to Charge Contribution/Pledge Payments

Your credit card will be charged for the amount and schedule selected above
First / Last Name of Credit Card Holder   
Mailing Address of Credit Card Holder    
Please Select a Credit Card Type       Visa     MasterCard     American Express 
I give authority to the above selected credit card company to honor payments drawn by you on my credit card for contribution/pledge payment as indicated above.  It is understood that your sending of a pre-authorized payment to the credit card company, as a payment becomes due, shall constitute valid notice of such payment due on this contribution/pledge.  When the credit card company honors the payment by charging my account, such payment shall constitute my receipt. 
Credit Card Number    Expiration Date (mmyy)   
We'll contact you by e-mail to confirm your completed contribution/pledge form
Thank You for supporting the Regional YMCA!