Community Fundraiser Form Your Information Title: Mr. Ms. Mrs. Miss Dr. Required * First Name: Required Middle Name: * Last Name: Required * Email: Required * Street 1: Required Street 2: * City: Required * State / Province: Required AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NL NS NT NU ON PE QC SK YT None Required * ZIP / Postal Code: Required * Phone Number: Required If you respond and have not already registered, you will receive periodic updates and communications from South Shore Health. * Question - Required - Have you read and agreed to our FAQs? Please select response Yes No * Question - Required - What is your connection to SSHS? * Question - Required - Are you an employee? Please select response Yes No * Question - Required - Fundraiser Name * Question - Required - Fundraiser Date Month Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year Year 2039 2038 2037 2036 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 * Question - Required - Is your fundraiser in honor or memory of someone? * Question - Required - What area of the Health System will your fundraiser support? * Question - Required - Do you need an online personal fundraising page? Please select response Yes No * Question - Required - How do you plan on raising money? Please make at least 1 selection from the choices below. Raffle Auction Ask for Donations Other Question - Not Required - If Other, please specify: * Question - Required - What is your fundraising goal? * Question - Required - Is SSHS the sole beneficiary? Please select response Yes No Please read our Terms & Conditions. * Question - Required - I accept the Terms & Conditions. Please select response Yes No * Question - Required - Authentication Change image Spam Control Text: Please leave this field empty