Survey - Community Partner Event Registration - Cook Children's Health Foundation

1.

About you

*

Name:

Title	First Required	Last Required

*

Email: Required

*

Street 1: Required

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

*

Date of Birth: Required

Date of Birth:

*2.

Question - Required - What is your preferred method of communication?

*3.

Question - Required - What is your connection to Cook Children's?
Please make at least 1 selection from the choices below.

	Current or former patient
	Family member of current or former patient
	Employee
	Existing donor
	Partnering company
	Other

*4.

What area of Cook Children's interests you the most?

(Select one of the available choices or enter a different value.)
Question - Required -

*5.

Fundraiser Type

(Select one of the available choices or enter a different value.)
Question - Required -

*6.

Question - Required - Please describe your event.

Please read the following terms and conditions. You must accept the terms in order for your fundraiser to be considered.

*7.

Question - Required - I accept the terms and guidelines.

*8.

Question - Required - Will you need a website for your fundraiser?