Connect Well Community Health (Lanark County) General Donation

Program(Required)

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Donations of $20.00 or more will receive a charitable receipt.

Donation Amount(Required)

Special Instructions

Credit Card(Required)

Cardholder Name

Card Details