Referrals

Important Information Please Read

Starting October 1, 2010, we will no longer be able to accept family activations through our web site. You will receive an email with an attached spreadsheet that you will need to use to enter and submit your family data. The spreadsheet includes specific instructions on how to enter and submit your families information. Additionally, you will be given a customer number that will need to be included with every activation on the spreadsheet. Please call if you have any questions 315-736-6643. We appreciate your cooperation and patience through this change. Thank you!

Family Activation Form

Instructions: If you have not changed your contact information and program choices, you can just include your company name and only sumbit the program recipient information. Be sure to print a copy for your records, before you hit the submit button. Thank you.

Program Sponsor Information:
Company Name:	* required
Contact Name:
Contact Phone:
Program Choices:
Program Choice:	Family Care Program Family Care Books Only Holiday Card Anniversary Card
# of Calls
Comments:
Program Recipient Information:
Title:
First Name:	* required
Middle Name:
Last Name:	* required
Mailing Address 1:	* required
Mailing Address 2:
City:	* required
State:	* required
Zip Code:	* required
Phone Number:
Name Of Deceased:
Date of Death:	* required
Relationship to Recipient:
Additional Information: