Donate

One Page Form

A * denotes a required field

This is a printable form. Please fill in the fields below and click the "Print" button below.

*First Name:
Middle Initial:
*Last Name:
*Street Address:
*City:
*State:
*Zip Code:
Day Phone: () -
Eve. Phone: () -
E-mail:

If sending check, please make payable to CP Rochester. If donating by credit card, please fill in the fields below.

We accept:
Visa, MasterCard, Discover, and American Express

NOTE: The minimum credit card donation is $5.00

*Charge Amount: $
*Card #: ---
Exp. Date: Month Year
Card Type:
Name on Card:
   

Once you have printed the form, mail to:

CP Rochester
3399 Winton Road South
Rochester, NY 14623