EmailMe Form - Snow Angels 2018-2019

Contact Information

Name *

First Last

Email: *

Phone *

### - ### - ####

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Cancer Center/Clinic Information:

Clinic Name *

Clinic Location (city) *

Clinic Phone: *

### - ### - ####

Doctor's Name *

First Last

Clinic Contact Person: *

First Last

Snow Removal Information

Please provide as much detail as possible to better serve your needs.

Residence Location *

Rural

City

Snow to be cleared from (check all that apply) *

Describe "Other"

Approximate Area
(length & width)

Level of Snow Removal

Less than 2 inches

2 inches or more

Do you require salt application?

Yes

No

Special Instructions/Requests

Snow Removal Service Provider

We need your assistance in finding a service provider for you. It is imperative that you feel comfortable with the service provider selected, so that your needs are met in a timely, and efficient manner.

Please select provider from dropdown menu, if you live outside of the Des Moines Metro, we will need your help finding a snow removal provider to assist you.

Snow Removal Company: *

Other Company Name:

City *

Phone *

### - ### - ####

Web Site (optional)

Verification

Signee verifies that the completed information is true.

Name *

First Last

Who is filling out this form? *

Terms & Conditions: I verify that the person listed above, under "Patient Name", is in need of snow removal services due chemotherapy treatments.

I am a patient battling:

I Agree to the Terms & Conditions *

I AGREE

Initials: *