Hospitalized Member Notification

If you know of a CIUW member who has recently been hospitalized, please let us know.

Name of Hospitalized Member: *

First and Last Name

Street Address:

Enter the hospitalized member's street address, if known

City, STate, ZIP:

Any or all of the hospitalized member's city, state, and ZIP code if known

Hospital:

Name of the hospital if known

Date Hospitalization Began: *

Date the member entered the hospital (approximate OK if exact unknown)

Date Left Hospital: *

The date the member was discharged, if known (or use best guess). If still hospitalized, use today's date and enter "Still Hospitalized" in the box below.

Additional Information:

Please add any details, such as the member's interests or hobbies, that might allow us to make a more personal expression of sympathy. Also, if the member is still hospitalized, please indicate that here.

Your Name: *

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