2017 Change Bandit Sign Up

* required information
Registration 
Registration Information
If Change Bandit is a Child, please provide parent's name in box provided.
Title:
First Name:*
Middle Initial:
Last Name:*
Parent/Legal Guardian Name:
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:
Cell Phone:
Birth Date:(mm/dd/yyyy)
Gender: Female   Male  
Have you been a Change Bandit in the past?: Yes
No
Fees
Child
Use this category if you are a child raising money on your own.
 
Family
Use this category if you are a family raising money together.
 
Individual
Use this category if you are an individual raising money on your own.
 
Additional Information
Do you have a story to share with 98.1 KDD listeners? Please send your story to Nicci Avalon. All stories will be edited to protect the privacy of the patient 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 personal 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: