Your Name *

First Name

Last Name

Start Date *

MM

DD

YYYY

End Date *

MM

DD

YYYY

Event Start Time

if applicable (form requires "seconds", enter 00)

Hour

Minute

Second

AM PM

Event End Time

If applicable (form requires "seconds", enter 00)

Hour

Minute

Second

AM PM

Address of Event *

Address the event will be held or the donation drive is to be collected.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Event Coordinator Name *

RLSIR person organizing your event, and the go to person for questions.

First Name

Last Name

Event Coordinator Phone *

Email of the RLSIR event coordinator

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