Change Bandit Sign-Up Form

CHANGE BANDIT CONTACT INFORMATION

Dr. Mr. Mrs. Ms.

CHANGE BANDIT NAME:

SCHOOL/BUSINESS/ORGANIZATION NAME:
(If the Change Bandit is a child, please include the name of a parent/guardian on the line below)

CHILD GENDER:
Male Female

CHILD BIRTHDATE (MM/DD/YYYY)
//

ADDRESS:

CITY/STATE/ZIP:
//

THIS ADDRESS IS A:
Residence School/Business

BUSINESS PHONE:

HOME / CELL / OTHER PHONE:

EMAIL ADDRESS:

CHANGE BANDIT PARTICIPATION

I would like to raise money for:
Akron's "Have a Heart, Do Your Part" Radiothon
Mahoning Valley's Mix 98.9 Miracles & Promises Radiothon

Please Select One:
Individual/Family
School - School District Name:
Business/Organization (less than 100 employees)
Business/Organization (more than 100 employees)
Akron Children's Hospital Department - Department Name:

How did you hear about the Change Bandit program (select one)?
Previous Change Bandit
Radio
Community event
Social Media (Facebook, Twitter, etc.)
Direct mail
Papa John's box topper
Other (please fill in) :

SHARE YOUR STORY!
Do you have a story to share with Radiothon listeners? Please use the following field to share your Akron Children's Hospital story. Some stories might be selected and possibly edited to be read on the air during Radiothon. By supplying a story, you give Akron Children's Hospital permission to use your personal name or business name.

I am unable to participate this year, but I would like to make a donation.
Click here to make a secure online donation.

I agree to abide by any state laws governing fundraising and all Akron Children's Hospital guidelines.



Bookmark and Share

iGrow iGrow
Sign up for our parent enewsletter
Contact Us

330-543-1000 (operator)

330-543-2000
(8 a.m.-4:30 p.m.)

E-mail

find a location
Find a location Type the first 3-5 letters of a specialty, service or location:
Or, view: a map, a list of all locations, locations by city or locations near me.
find a doctor
Find a doctor Type the first 3-5 letters of the name, location or specialty:
Or, view a list of all doctors by name, location and specialty.