Name of Group:


Contact Name:


Address:


City/State:    


Zip:


Daytime phone number with area code:
 

Mobile number with area code:


E-mail address:


Website:


Type of group
(school, after-school program, hospital,
Adult or Professional, Civic, etc.):


Age range:


Can you provide staff/volunteers?                               
yes no

How many?


Approximate time/date to schedule:

How did you hear about Portraits of Hope and the Garden in Transit project?

Additional information (optional):