Fields marked * require an entry.

Each vendor is encouraged to donate a raffle basket to Buffalo Hearing & Speech Center's Healthy YoU 2012 event!

Buffalo Hearing & Speech Center employees who attend can enter their raffle tickets to have the chance to win a sponsored vendor basket!

Note: If you are unable to attend Healthy YoU, you may still donate a basket on behalf of your organization.
Please drop off or send raffle baskets to:

                        Buffalo Hearing & Speech Center
                        Attention: Johnna Matusik
                        50 E. North st
                        Buffalo, NY 14203

Please complete the form below to donate:
**you will need to complete the contact information again if you have already registered**

Raffle Basket/ Item Donation

Item Information

Item Name:*

Estimated Value $:*

Item Description:*

(if applicable: please describe what your basket will contain):

I am a(n):*

Individual Donor

Business Donor

I would like to remain anonymous:*

Yes

No

Comments & Other Instructions:

Contact Information

Company:*

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country / Location:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Work Phone:

Email:*

Raffle Basket/ Item Donation

About Us

Follow Us