Northwell Health Systems Registration
Name
*
First Name
Last Name
Hospital/Site
*
Department
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address for Acknowledgement
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I would like to receive emails from Island Harvest
*
Yes
No
Expected number of participants in the food drive
*
Food Drive Begin Date
*
-
Month
-
Day
Year
Date
Food Drive End Date
*
-
Month
-
Day
Year
Date
Our food drive goal in pounds is:
*
Would your group be interested in hosting a Virtual Food Drive?
*
Yes
No
Maybe- please send us information!
We will need a Food Drive Box (1'x1'x3')
*
Yes
No
We will be delivering our collected food to:
*
Hauppauge
Uniondale
Our food drive is going to collect more than 500 lbs of food. Please send a truck!
Please share any additional information or details if applicable.
Submit
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