Melha Event request

MELHA UNIT's ONLY And Members of the Shrine Request For Clowns
Your Full Name *

First Name Last Name
E-mail *
Phone Number *
Unit Name - *
What Type of event is this. *

MELHA Approved event (ie Parades and Melha Fund raiser.) Unit Fund Raiser Circus Promotional An event for me or my Family, or an event NOT related to MELHA or the SHRINE Hospital Event

Address of Venue *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date of event *

Month Day Year Date Picker Icon
Time of event *

: Hour Minutes AM/PM Option
until
until : Hour Minutes AM/PM Option
Give us a brief explanation of what type of event this is *
Enter the message as it's shown *
Should be Empty: