Name *

First Name

Last Name

Address *

Where you would like packaging sent to you, or where you would like your Sizable Item donation picked-up.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Pick up Date

Arrange meet up to hand deliver your donation to LSH. If you have a Sizable Item Donation the pick up will be made at your home address.

MM

DD

YYYY

Pick up Time

Hour

Minute

Second

AM PM