Contact Information 
Primary Donor
First Name*
Last Name*
Language Preference*
Street Address*
Postal Code*
Additional Donor #1 (if applicable)
Donor 1 First Name
Donor 1 Last Name
Donor 1 Telephone
Donor 1 Email
Additional Donor #2 (if applicable)
Donor 2 First Name
Donor 2 Last Name
Donor 2 Telephone
Donor 2 Email
Additional Donor #3 (if applicable)
Donor 3 First Name
Donor 3 Last Name
Donor 3 Telephone
Donor 3 Email
More than 3 Donors
Location Selection 1:
Location Selection 2:
Location Selection 3
Can’t find your location? Check this box for assistance.
Permission for the NCC to communicate with you via email regarding this request.

The information collected in this form is required for the administration of the NCC Park Bench Program.  In accordance with the Privacy Act, personal information collected will only be used for the purpose for which it was initially obtained or compiled and accessed by authorized personnel.  Furthermore, the NCC collects and manages the personal information in this application in accordance with its Privacy Policy.  

Note that NCC uses an external third party service (ClickDimensions) to transfer information about your application from this website to our internal systems. For more information on ClickDimensions security and privacy, please consult section 4.3 to 4.6 of their Security overview on their website. If  you wish, you can choose to provide your information by phone at: 613-239-5000.