Saturday 10/02/2010

Paint Your Heart Out Event Registration Form 10/02/2010 Saturday


Event Date: Saturday, 10/2/10
Event Start Time: 9:00 AM

Volunteer Group Name: Palm Beach Atlantic University

Number of Volunteers: 15-20


Group Leader Contact: Melissa Groller Group Leader Phone/Email: Melissa_Groller@
pba.edu

PYHO/SWA Event Contact: Joanna Aiken PYHO/SWA Contact Phone/Email: 561-358-2163
jaiken@swa.org


Homeowner Information

Name: Susie Childress
Address: 716 48th Street
West Palm Beach
33407

Square Feet: 832

Color Selection: Stony Creek Base Off White Trim

Comments: Legally blind – low income.

Directions: 45th Street East – Left on Pinewood - Right on 48th Street - End at 716 48th Street.

Please review the information and make sure it is accurate. Your signature below confirms your commitment to participating in the PYHO event described event. Once signed, please fax back to Heather Levy or Joanna Aiken at (561) 640-3400.



Volunteer Group Leader Date



PYHO/SWA Representative Date