*
Required
Your Information
First Name
*
required
Last Name
*
required
Email
*
required
Phone
*
required
Select List
Please Select…
Student
Parent
Faculty
Staff
Alumnus
Other*
*If Other, please describe
Recipient Information
First Name
*
required
Last Name
*
required
Email
Phone
Street Address
City
State
Zip
Recipient’s relationship to Galloway
*
required
Please Select…
Student
Parent
Faculty
Staff
Alumnus
Other*
*If Other, please describe
Helping
How has the recipient been affected?
*
required
(Death in family, surgery, hospitalization, illness, birth, marriage, etc.). Please be as detailed as possible.
What help might be appreciated?*
Note of support
Donation
Food (indicate special requests or allergies below)
Toy or book (please provide details below)
Please list any details or additional items here
Please only submit this form if you believe that the recipient would like to receive an acknowledgment from the Galloway Cares committee.
Thank you for caring,
Tania Au and Tasha Bender-Cummings
Co-Chairs, Galloway Cares Committee
Please send a confirmation email to the address below*: