Cornwall Central Teachers Association
P.O. Box 719
Cornwall, New
York 12518
TO: CCTA Social/Welfare Committee
From: ___________________________________ (person submitting form)
Regarding: _______________________________ (name of staff person)
Event: ___________________________________ (birth, death, wedding,
illness, etc.)
Is above a CCTA member?
Yes No
Is the event an ILLNESS?
Yes No
Is the member hospitalized?
Yes No
Will the member be in the hospital long
enough for flowers to reach there?
Yes No
If yes, name and address of hospital:
__________________________________________________________
__________________________________________________________
In the event of DEATH in the family:
Full name of deceased
___________________________________
Relation to staff person
___________________________________
Memorial donations are to be sent to:
Name of organization
_____________________________________
Full mailing address of
organization:
___________________________________________________
___________________________________________________
Please submit this form to the appropriate person in your building.