Children's Legacy Advisors: Application Form

Please complete the application below to begin your membership as a Children's Legacy Advisor. If you have problems submitting this form, please email Ron Streitz, VP Planned Giving, or call (800) 841-4642.

Contact Information

Name:

Title	First Required	Middle Required	Last Required	Suffix

Email: Required

Street 1: Required

Street 2:

City/State/ZIP:

City Required	StateRequired	ZIPRequired

Country:

Phone Number:

Employer: Required

Yes, I would like to receive e-mail from Children's Hospital & Research Center Foundation

Email Format:

Yes, I would like to receive postal mail from Children's Hospital & Research Center Foundation

Remember me.

*2.

How did you hear about us?
Please make between 1 and 5 selections from the choices below.

	Seminar (indicate which seminar below)
	Client (enter client's name below)
	Associate (enter associate's name below)
	Advertising
	Other (please describe)