Mercy Stork Affair Pre-Registration

Thank you for your interest in Mercy Stork Affair. Please complete the following information to pre-register and be eligible for prize drawings.

You reserve the right to revoke your permission for Mercy to use this information by calling (515) 247-3050.

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1. How did you hear about Mercy Stork Affair?

Newspaper

Friend

T.V.

Online

Radio

Doctor

Poster

Postcard

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2. Are you currently expecting?

Yes

Already Delivered

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3. If you answered yes to the above question, what is your expected due date?

Due Date:

Date

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4. If currently expecting, where will you be delivering?

Mercy Women & Infants' Center

Mercy West Lakes

Undecided

Other hospital

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5. May we share your name with vendors who donated prizes?

Yes

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6. Please provide your contact information.

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *