We have had overwhelming requests to support our Centra healthcare workers during this COVID-19 pandemic. Thank you for coming along side us as we remain on the front-line caring for our community. This survey will help us to coordinate the receipt and delivery of your gifts and remember your kindness, and acknowledge your generosity.

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* 1. Name:

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* 2. Organization (if applicable):

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* 3. Mailing address with city, state, zip:

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* 4. Phone Number:

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* 5. Email Address:

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* 6. Amount and description of items you wish to donate:

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* 7. Estimated value of donated items:

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* 8. When would you like to drop off the donation? (Donations for all shifts must be between the hours of 9AM-3PM)

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* 9. Is there a specific department and/or shift you wish to gift items to?

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* 10. Additional Comments:

Thank you for your generosity!
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