If you are interested in Lifesquire donating a gift certificate for our services for your event, please fill out the following form. Submissions are accepted quarterly on a first come, first serve basis.

 
Name *
Name
Type of Assistance
If applicable
Phone *
Phone
Mailing Address *
Mailing Address

Your privacy is important to us! The information you submit to Lifesquire by using this e-form is for internal use only.  We will never sell your name, e-mail address, contact information or question information to other entities.