GRC Raffle Donation Form

First Name *

Last Name *

Email *

Hospital or Company Name *

Item I Will Donate: *

Description of Item Donated: *

Value of Item Donated (must be $75 or more): *

Is this a personal donation or donation made by your hospital or company? *

Personal

Hospital or Company

Will you bring the item to Spring Conference or mail it by April 15? *

I will bring it to the conference

I will mail it, please send me the mailing address

I will need someone to pick it up, please contact me to make arrangements