Hospital Monkey In My Chair Request
Please fill out the form to receive your Monkey In My Chair kits and/or brochures.
Please select
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My hospital/organization is new to the Monkey In My Chair program
My hospital/organization has been using the Monkey In My Chair program
Already a participating hospital?
You don't need to fill out the form below if all your information is still the same. You can just email Heidi at monkey@lovechloe.org to request more kits!
Hospital/Organization Information
Name of Hospital/Organization
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Contact Person
*
First Name
Last Name
Position/Title
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Contact Person (optional)
Name
First Name
Last Name
Position/Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Program Options
Please select your program choice
Please Select
Kits and brochures
Kits only
Brochures only
We are able to send kits in boxes of 3 or 5 and we typically send 25 brochures at a time. Please indicate if you need more than 25 brochures. You will be prompted to select the number of kits you need if you choose kits as a program choice.
Number of kits requested
Please Select
3
5
8
10
If you would like to request more than 10 kits, please indicate that in the comments below.
Comments
Please acknowledge the following:
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If you chose to have Monkey In My Chair kits, you will be responsible for ensuring all of those kits are registered by the families. Registration forms will be attached to each kit sent to the hospital. Forms can be mailed, faxed or emailed. Registration can also be filled out electronically on our website www.monkeyinmychair.org
Please verify that you are human
*
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