COTA MIRACLE MAKERS

COTA

GIVE HOPE

MAKE A MIRACLE

Your Miracle Maker Activity Report

The Children’s Organ Transplant Association is very grateful for the time and effort you spent organizing a COTA Miracle Maker activity.  Please complete this form so COTA can add your activity to COTA Miracle Maker results from across the country.

Thank you for Giving Hope and Making Miracles!

*Required information

Do not enter anything in this field!

First Name: *

Last Name: *

Organization or Company Name: *

Your Position:

Address: *

City: *

State: *

- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code: *

Email: *

Phone: *

Report of your COTA Miracle Maker Activity

Date of Activity: *

Location of Activity: *

Description of Activity: *

Number of people attending activity: *

Number of volunteers: *

Number of donors added to donor list(s): *

Media coverage: *

Are photos available?: *

No Yes

Did you use tools, tips or resources provided by COTA?: *

No Yes

If yes did you find these materials helpful?: *

No Yes

What COTA resources did you find most helpful?: *

What resources would you suggest COTA provide in the future?:*

Amount you plan to raise: *

Have funds been sent to COTA?: *

No Yes

Have funds been deposited into a COTA bank account?: *

No Yes

If yes, which account?:

Chase Bank of America Wachovia Wells Fargo

Contact me with more opportunities to help COTA give hope and make miracles: *

No Yes

If you have not yet sent or deposited activity proceeds:

Cash may be deposited in one of these COTA bank accounts:

Chase
COTA Miracle Makers
Account Number: 2917125714

Bank of America
COTA Miracle Makers
Account Number: 2290 0820 9370

Wachovia Bank
COTA Miracle Makers
Account Number: 3000025117027

Wells Fargo Bank
COTA Miracle Makers
Account Number: 6733374216

Checks may be mailed to:

One Million Miracles
Children's Organ Transplant Association (COTA)
2501 West COTA Drive
Bloomington, Indiana 47403