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Long Island Dine11.org Hospital Partner Sign Up Form
Please complete this form to participate as a Hospital Partner in Dine11
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* Indicates required question
Name Of Hospital
*
Your answer
Primary Address
*
Your answer
Primary Contact
*
Your answer
Primary Phone Number
*
Your answer
OUR DRIVERS NEED TO KNOW LOCATION & SPECIFIC DIRECTIONS FOR ALL DROP OFFS
Drop Off Location -- Street
Your answer
Drop Off Location -- City
Your answer
Drop Off Location -- State
Your answer
Drop Off Location -- Zip Code
Your answer
Drop Off Contact Name
OUR DRIVERS NEED THE NAME OF THE CONTACT PERSON THEY WILL BE MEETING
Your answer
Drop Off Contact Phone Number
OUR DRIVERS NEED THE NUMBER OF THE CONTACT PERSON OR PERSONS THEY WILL BE MEETING
Your answer
Drop Off Contact Email
OUR DRIVERS NEED THE EMAIL OF THE CONTACT PERSON THEY WILL BE MEETING
Your answer
Lunch Shift - Head Count
*
Your answer
Lunch Shift - Time
*
Time
:
AM
PM
DInner Shift - Head Count
*
Your answer
DInner Shift - Time
*
Time
:
AM
PM
Three Busiest Days (In order of urgency)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Required
Hospital Location
*
If you are located on the border of an area, you can select more than one area.
Western Nassau
Eastern Nassau
Western Suffolk
Eastern Suffolk
Required
Urgent dietary restrictions - If any
Your answer
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This form was created inside of MARCH ON.
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