EmailMe Form - Coffee Break® Registration Form

Name *

First Last

Organization/Company Name (if applicable)

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone *

### - ### - #### Ext. ###

If no extension, please enter 000 into the box above

Fax

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

Email

Date of Coffee Break®

DD / MM / YYYY

*

The above is a firm date.

The above is a tentative date.

We want to host a Coffee Break® but don't have a date yet.

Note: To be eligible for the champion title and other awards, please return donations by November 4, 2019.

Choose Your Coffee Break® Kit *

Small (<20 people)

Medium (20-50 people)

Large (>50 people)

Mobile Kit (Forget-me-not cut-outs)

A Coffee Break Host Kit contains a donation coin box, coffee, balloons, forget-me-not cut-outs, posters and other promotional materials

Items to include in host kit

Promotion of Coffee Break®

Is your Coffee Break® event open to the public? *

Yes

No

Do you want our help promoting your event?
(ie. Alzheimer website, social media, e-newsletter) *

Yes

No

Please provide any other important information about your event.

Speaker

I would like to book a speaker for my event. Please contact me.

If you would like to book a speaker, please indicate the date and time you would like the speaker to attend.

Donation Matching

Our organization will support Coffee Break® by matching employee contributions and/or mobile sales.

I want to do more, please contact me about:

Other ways to help

Other events (ie. Walk for Memories, Tag Days)

Minimum Commitment

I commit to raising a minimum of $100 at my Coffee Break® event.

Contact Information:

Barrie Office
20 Anne St. S. Unit 3 P.O Box 1414
Barrie, ON L4M 5R4
Telephone: 705-722-1066
Toll Free: 1-800-265-5391
E-mail: funddev@alzheimersociety.ca