2017 Change Bandit Sign Up

Thank you for signing up as a Change Bandit for the 2017 Have a Heart, Do Your Part Radiothon presented by 98.1 KDD.
* required information
Registration 
Registration Information
Title:
First Name:*
Middle Initial:
Last Name:*
Job Title:
Gender: Female   Male  
Company Name:*
School:
Department:
Business Phone:*
Cell Phone:
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Is this address a:* Business Address
Residence Address
Address Notes:
Have you been a Change Bandit in the past?: Yes
No
Fees
School
Use this category if you are raising money as a school or daycare.
 
Business under 100 employees
Use this category if you are raising money as a company with less than 100 employees
 
Business over 100 employees
Use this category if you are raising money as a company with over 100 employees.
 
Hospital Department
Use this category if you are a department of Akron Children's Hospital.
 
Additional Information
Do you have a story to share with 98.1 KDD listeners? Please email Nicci Avalon.to share your story. All stories will be edited to protect the privacy of the patients and family. Some stories might be selected to be read on the air during Radiothon. I give Akron Children's Hospital and 98.1 KDD permission to use my business name to promote the Have a Heart, Do Your Part Radiothon.
I give permission: Yes
Where did you hear about this?:*
If you received a Change Bandit letter in the mail, please provide the code at the bottom of your sign-up form: