| Name: | Title* | First* | Last* |
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| E-mail*: |
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| Address 1*: |
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| Address 2: |
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| City/State/Zip: | City* | State* | Zip* |
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| Phone*: | ()
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| Fax: | ()
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2. Organization/ Company Information
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| Organization/Company Name*: |
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| Affiliation with Organization/Event*: |
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| Address 1*: |
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| Address 2: |
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| City/State/Zip: | City* | State* | Zip* |
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| Phone*: | ()
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| Fax: | ()
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| Website Address: |
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Please provide a description
of your organization*:
(Brief summary about mission of
organization or company
background) |
(Maximum response 250 characters) |
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3. Fundraiser/Event Information
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| Event Name/Type*: | |
Description about fundraiser/event*:
(Brief summary and/or goals of event
or product information) |
(Maximum response 250 characters) |
| Event Date*: |
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| Event Start Time*: |
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| Event End Time*: |
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| Expected Attendance*: | |
| Projected Sales*: | |
Corporate Support for Event*:
(Sponsors, media, in-kind donations) | |
If there are sponsors,
please list: |
(Maximum response 250 characters) |
Target Audience*:
(gender, age, race, breast cancer survivors, education level, languages spoken other than english, etc.) |
(Maximum response 250 characters) |
Please provide a brief description about your method for raising funds*:
(silent auction, ticket sales, drawing, raffle, product sales, etc.) |
(Maximum response 250 characters) |
How much money do you anticipate donating to Komen North Central Alabama from this fundraiser? If the donation is based on a percentage, please indicate that amount (e.g. 10% of ticket sales, 100% of profits)*:
(Please be specific for each fundraiser initiative-raffle, tickets, sales, etc. Indicating a donation amount will not obligate you to that amount) |
(Maximum response 250 characters) |
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4. Venue Information
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| Facility Name*: |
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| Address 1*: |
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| Address 2: |
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| City/State/Zip: | City* | State* | Zip* |
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| Venue Website: |
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Venue Contact*:
(Name of contact you are working with at venue) |
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| Please provide directions to the venue*: |
(Maximum response 250 characters) |
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4. Komen North Central Alabama Support
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Please describe in detail the type of support you are seeking from our Affiliate*:
(e.g. assistance with promotions, ticket sales, plans for event, etc.) |
(Maximum response 250 characters) |
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5. Volunteer Information
If you are requesting assistance with volunteers to help staff the event, please provide the following information.
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| Number of Volunteers Needed: |
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| Volunteer Start Time: |
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| Volunteer End Time: |
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| Role and/or Responsibility of Volunteers: |
(Maximum response 250 characters) |
How should the volunteers dress?:
(business, business casual, formal, casual, etc.) |
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Accommodations for Volunteers:
(These are not required, but encouraged if possible: refreshments, transportation, gifts, etc.) |
(Maximum response 250 characters) |
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6. Materials:
Educational materials (such as Breast Self-Exam Cards and informational brochures, etc.) are available for your event, free of charge. Please indicate your needed quantity and we will forward you an assortment of literature.
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| Number of educational materials: |
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Supplies-We also have the following supplies available free for your event, please provide quantity.
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| Pink Lapel Ribbons: |
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| Donation Envelopes: |
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| Will you be providing goody bags?: | |
| If yes, how many?: |
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7. Form Verification:
Please type in the word you see in the follwing box:
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