ANNUAL SURVEY
Deadline: August 31

Form AS OF May 23, 2017

Please use information from your Organization's (Auxiliary's) last fiscal year to answer these questions.

Hospital or Healthcare Facility:

Information provided in this survey will be used to calculate your Annual Dues based on the total number of Active Adult Volunteers in your Hospital or Healthcare Facility. Dues will be computed at $0.35 per Active Adult Volunteer in addition to a Base Charge calculated as a function of the total number of Active Adult Volunteers reported. Base Charges are: 1-50 Active Adult Volunteers; $15.00; 51-100, $30.00; 101-200, $45.00; 201-400, $60; and Over 400, $80.

Do Not Send Dues Now---Dues Notices will be mailed in January!


INFORMATION ABOUT ADULT VOLUNTEERS

Total Number of ACTIVE ADULT VOLUNTEERS:
Total Number of HOURS Donated By ACTIVE ACULT VOLUNTEERS:

INFORMATION ABOUT TEEN (JUNIOR/HIGH SCHOOL) VOLUNTEERS

Total Number of TEEN (JUNIOR/HIGH SCHOOL) Volunteers:
Total Number of HOURS Donated By TEEN (JUNIOR/HIGH SCHOOL) Volunteers (no commas):

INFORMATION ABOUT MONETARY CONTRIBUTIONS

MONETARY CONTRIBUTIONS TO: Hospital or Healthcare Facility $
MONETARY CONTRIBUTIONS TO: Community Programs $
MONETARY CONTRIBUTIONS TO: Scholarships $

Your Email Address:


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Please send any other information or requests via the COMMENTS box