Dia de las Madres Agency Participation Form

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October 14, 2021
Make checks payable to Bethesda Health Clinic
409 W. Ferguson, Tyler TX 75702

Agency Name *

What services does your agency provide to the community? *

Agency Address *

Agency Contact *

Email and Phone Number *

Each participating agency will be provided tent space, a 6 ft table and 2 chairs. Lunch and t-shirts will also be provided to 2 agency representatives. If your agency would prefer to bring your own tent, please let us know below: *

Will bring our own tent

Will use tent space provided by Bethesda

Each agency will be required to have at least one person at their booth that speaks Spanish. Please note that you agree to this requirement. *

Yes

The cost of the booth space is $50. You may pay via check or can donate online through the Bethesda Health Clinic website. If donating online, please "dedicate" your donation in honor of "DIA." *

I will send a check made out to Bethesda Health Clinic

I will pay online.

Please enter the tshirt sizes for your team (2 per booth). Sizes available are S-2XL. *

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