MedWish International · MedWish Gala Registration Form 2021

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Email

*

Verify Email

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Phone

*

Event Donation

There is a suggested donation of $250 in lieu of a ticket to attend. All donations will benefit MedWish International's life saving mission.

Donation to MedWish International

$

Experience Enhancement

Would you like to enhance your Gala experience with a VIP special delivery? This will include a meal inspired by the work of MedWish and other surprise goodies delivered right to your doorstep safely and contact free!

*Please note that special delivery is location contingent. Deliveries will be made on Thursday, October 28th. Stay tuned for additional information to confirm delivery details.

VIP Special Delivery	Quantity
$125 - Per Person

Donation Acknowledgement

*

In an environmental effort to reduce paper usage, MedWish donors have the option to receive thank you letters/donation receipts via email or hard copy. Please select which manner you would prefer to receive your donation acknowledgement.

EVENT REGISTRATION & DONATIONS

Event Donation

Experience Enhancement