Dine11.org Hospital/Community Center Partner Sign Up Form
If your hospital or department is directly impacted by COVID 19, or a Community Center helping people directly who are suffering because of COVID 19, please complete this Sign Up Form and we would love to serve you!
Name Of Hospital/Community Center *
Primary Address *
Primary Contact *
Primary Phone Number *
Primary Email *
Drop Off Location
OUR DRIVERS NEED TO KNOW LOCATION & SPECIFIC DIRECTIONS FOR ALL DROP OFFS
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) - 1st Choice *
Three Busiest Days (In order of urgency) - 2nd Choice
Three Busiest Days (In order of urgency) - 3rd Choice
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
How is your department directly servicing Covid patients during this crisis?
Submit
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