All fields are required unless noted otherwise
Name of Hospital
Address (Street, City, and Region if applicable)
Zip Code (optional)
Country
GPS Address
Why does your hospitals need the supplies? What is the current state of the hospital? What would these supplies mean to your hospital?
Point of Contact
Your email (optional)
WhatsApp Phone Number
Type your name as a sworn affidavit that you are the point of contact for this hospital. Typing your name is identified as a signature.
