McSweeney Regional Senior Center
47 Cresent Street
Willimantic, CT 06226
Make checks payable to the McSweeney Senior Center
| Trip Name | Number of Travelers | Amount |
| 1.______________________ | _______________ | $________________ |
| 2.______________________ | _______________ | $________________ |
| 3.______________________ | _______________ | $________________ |
| 4.______________________ | _______________ | $________________ |
| 5.______________________ | _______________ | $________________ |
| Total Amount Enclosed $__________ |
Full Legal Name:_______________________________
(as it appears on your picture ID.)
Address:____________________________________
City:_____________________________ State:_________ Zip:____________
Telephone:________________________
Liscense Plate Number: ____________________________________
We give the Willimantic Police a list of our traveler's license plate numbers so they can keep an eye on our traveler's cars in the parking lot.