Hot Rods for Hospice Registration

First and Last Name:

Your Email:

Please confirm your email address:

Phone Number:

Car Details: Please include your cars year, make and model (and name if applicable):

How will you be paying your donation?
CashChequeEtransfer

Please note we will follow up by email with instruction on where to drop off your cash/cheque or where to send your etransfer.

Your message (any additional information you would like to provide)