Volunteer Trip Payment

Restavec Freedom Alliance, BEM In., is a non-profit, 501(c)3 program. If you are a volunteer, or are paying on behalf of a volunteer, please submit the form below. You may also send a check to 17 Windham Green Road, Windham CT 06280.

Volunteer Name*
First Last
Email*
Phone Number:
Trip Payment Options*
Please select your payment amount for this transaction. The total cost of the RFA trips is $1800 and can be made in two installments.
- Payment 1 - $900
- Payment 2 - $900
- Combined Payment - $1,800
Total
$ 0.00
Credit Card*

American Express
Discover
MasterCard
Visa
JCB
Maestro
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CAPTCHA
Verification*
Select yes if you have verified your credit card information above.
- Yes