SAVING FACE FUNDRAISING CAMPAIGN: ENROLLMENT FORM FOR MEDICAL DOCTOR OFFICES

TO COMPLETE AND SUBMIT THE FORM BELOW, YOU MUST BE AN AUTHORIZED REPRESENTATIVE OF A MEDICAL DOCTOR’S OFFICE. BY COMPLETING AND SUBMITTING THIS FORM, YOU, AS A REPRESENTATIVE OF A MEDICAL DOCTOR’S OFFICE, ARE AGREEING TO ENROLL THE DOCTOR’S OFFICE YOU REPRESENT IN THE SAVING FACE FUNDRAISING CAMPAIGN, AS DESCRIBED IN THE ENGAGEMENT TERMS LISTED BELOW.

Medical Doctor's Name *
Medical Doctor's Name
Licensed Doctor's Full Name
Office Manager's Name or Other Contact Person at the Office
Select which week your office would like to hold the campaign, and our team will set the date together with you.
Preferred Campaign Date: *
Preferred Campaign Date:
Within the date range you selected above, which date would your office prefer to hold the Saving Face campaign?
What Questions Do You Have?
I Have Read And Agree To The Saving Face Campaign Terms of Engagement *
SAVING JANE "SAVING FACE FUNDRAISING CAMPAIGN" TERMS OF ENGAGEMENT: THIS IS WHERE THE TERMS GO.