Participation Form

If you are interested in joining our cause to fight cancer, please complete the form below.

Click here for a printable application. Return completed application via email to

Note: Fields marked with an asterisk (*) are required.

First Name: *
Last Name: *
City, State, Zip:
Type of Event or Activity:
Date and Time of Event or Activity:
Contact Person's Name:
Phone Number:
In the space below, please outline your donation to The Foundation at East Jefferson General Hospital (i.e. a percentage of the proceeds of sales for a day, a week or a month, a flat dollar amount, etc.). Thank you for your participation and for joining the fight against cancer.