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Donation Request
Please fill out this form if you would like to be considered for Haven Box donations at your location.  You must be a hospital provider or victim service organization providing medical advocacy to Survivors at hospitals located in RI, MA or CT.  Completion of this form is not a guarantee of donation but will place you on a prioritization list based on the factors below.  

*For continued partnership, a monthly report is required for our data purposes.  This report will be emailed to the contact person listed on this form.
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Email *
Hospital and Organizational Information
For the purposes of Sections 1 and 2 of this form, "organization" will be used when referring to both hospitals and victim service providers.
Name and address of your organization? *
Geographical service area(s)? *
Name of contact person? *
Email and phone of contact person? *
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