General Information

Hospital Name*

Your City and State*

Contact Name*

Contact Phone Number*

             Fax Number

Cell/Home Phone (opt.)

Second Contact Person

Second Contact Ph. Number

Best time to reach

Tell us a little about your hospital

Number of Beds

Number of Employees

Dates of Interest (1)

for a possible fundraisers

Dates of Interest (2)

for a possible fundraiser

Additional Comments/Requests