Name *

First Name

Last Name

Best way to contact: *

Email

Phone

Phone *

(###)

###

####

Date of Event: *

MM

DD

YYYY

Is this a memorial event?

Yes

No

Would you like a representative from Oak Ridges Hospice to speak at your event?

Yes

No

Do you require any promotional materials from Oak Ridges (logos, materials, etc.?) *

Please note: permission is required before any ORH assets can be used by a third party.

Yes (specify below)

No

Disclaimer *

By checking this box, you acknowledge that Oak Ridges Hospice can contact you regarding your inquiry to host a third party event. For any points of clarification regarding the parameters of hosting a third party fundraising event, please review the Third Party Event Package.