Coffee Break® Registration Form
Thank you for registering to host a Coffee Break®.Your support is greatly appreciated!
Organization/Company Name (if applicable)
Address Line 2
State / Province / Region
Postal / Zip Code
If no extension, please enter 000 into the box above
Date of Coffee Break®
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?
Do you want our help promoting your event?
(ie. Alzheimer website, social media, e-newsletter)
Please provide any other important information about your event.
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.
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)
I commit to raising a minimum of $100 at my Coffee Break® event.
20 Anne St. S. Unit 3 P.O Box 1414
Barrie, ON L4M 5R4
Toll Free: 1-800-265-5391