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Name *

First

Last

Multiple Choice

4 to 9 years old
10 to 16 years old
17 to 25 years old
26 to 35 years old
36 to 55 years old
56 and up

Phone *

Email *

Postal address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

There are many ways to submit your donation:

By Interac e-Transfer to the following email: ensemble100@acpol.com with the password: Hearst100
In person at the Hearst branch (908 Prince Street).
By phone at 705-362-4308.
By contacting your Caisse advisor by phone or email.

Do you wish to be identified as a contributor to this project and be featured in all promotional communications?

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