HAT Radical Access - New Website Intake Form

Thank you so much for your support and your generosity!

This is an incredibly difficult time for all of us and with the uncertain nature of the coming months, it truly does mean the world when our patrons are able to give back to help us stay afloat during this tumultuous time.

Whether it's in person, via radio waves, or in cyberspace - we are committed and willing to do whatever it takes to deliver on our promises as we reach our funding goals. Your contribution is going to ensure we have stability and consistency as an organization through COVID and beyond.

In the coming months - however we find ourselves connecting with one another - know that your action today is responsible for a bold and radical experiment and we pledge to respect your contribution, continuing to give everything right back to the community we love.

Just a few quick questions and we will be able to add your pledge to our total!

No payment information at this time: we'll be contacting you directly to securely take your credit card information or arrange for cheques so make sure you leave a phone number we can reach you at.

Thank you for trusting us and joining us on this radical new adventure. A lot of people talk about changing the world. Here we go!
1.Name for Program Acknowledgement (can be couples):(Required.)
2.Official Name for Tax Receipt(Required.)
3.Phone Number (we will need to call you to confirm payment):(Required.)
4.Updated Mailing Address (if relevant)
5.E-mail Address:(Required.)
6.How much are you able to pledge (per month) for your Monthly Donation?(Required.)
7.What day of the month would you like us to deposit your monthly donation?(Required.)
8.What is your credit card number?(Required.)
9.What is the expiry? (MM/YY)(Required.)
10.What name is on the card?(Required.)
11.What is the 3 digit code on the back of the card?(Required.)