Long Island Dine11.org Hospital Partner Sign Up Form
Please complete this form to participate as a Hospital Partner in Dine11
Name Of Hospital *
Primary Address *
Primary Contact *
Primary Phone Number *
OUR DRIVERS NEED TO KNOW LOCATION & SPECIFIC DIRECTIONS FOR ALL DROP OFFS
Drop Off Location -- Street
Drop Off Location -- City
Drop Off Location -- State
Drop Off Location -- Zip Code
Drop Off Contact Name
OUR DRIVERS NEED THE NAME OF THE CONTACT PERSON THEY WILL BE MEETING
Drop Off Contact Phone Number
OUR DRIVERS NEED THE NUMBER OF THE CONTACT PERSON OR PERSONS THEY WILL BE MEETING
Drop Off Contact Email
OUR DRIVERS NEED THE EMAIL OF THE CONTACT PERSON THEY WILL BE MEETING
Lunch Shift - Head Count *
Lunch Shift - Time *
Time
:
DInner Shift - Head Count *
DInner Shift - Time *
Time
:
Three Busiest Days (In order of urgency) *
Required
Hospital Location *
If you are located on the border of an area, you can select more than one area.
Required
Urgent dietary restrictions - If any
Submit
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