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2023 Change for Life Registration
Change for Life will run from Mother's Day to Father's Day. Please complete this short form to reserve your bottles today!
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* Indicates required question
Email
*
Your email
Church/Organization Name
*
Your answer
Church/Organization Phone Number
*
Your answer
Mailing Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
Your answer
Physical Address (if different from mailing address)
Your answer
Contact Person(s) & Position
*
Your answer
Contact Person's Phone Number
*
Your answer
Contact Person's Email Address
*
Your answer
Number of standard bottles requested (for individual collection):
*
25
50
100
150
200
Other:
Number of large bottles requested (for group collection):
Your answer
Would you like a short, informative video?
Yes! Deliver electronically via email to the contact person listed above.
Yes! Please include a DVD with the video in our materials packet.
No video needed.
Would you like to pick-up your Change for Life supplies, or have them delivered?
*
Your answer
Special instructions/comments?
Your answer
Name of person submitting this form:
*
Your answer
Thank you! Your Change Changes Lives!
Questions? Contact Jordynn Griffith at (417) 623-0131 or via email at
JordynnG@choicesmedical.org
A copy of your responses will be emailed to the address you provided.
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