• Please provide the following contact information:

    Organization
    Street Address
    Address (cont.)
    Town
    County
    Postal Code
    Director
    Work Phone
    FAX
    E-mail
    Website

 

  • Additional Contact Person:

    Name
    Title
    Work Phone
    FAX
    E-mail

  • Additional Information

    Registered Non-Profit Identification Number :
    Approximate Number of Children
    (less than 15 years old) served: 


  • Other information which may be helpful, including problems that could be helped with our assistance:


  • Briefly describe each recreation and/or education equipment needed, cost, and groups to benefit: