Community Fundraising Request Form

Contact Information

Contact Name:(Required)

Prefix First Last

Organization:

Briefly describe your organization:

Does your organization have a 501(c)(3) status?

Yes

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone:(Required)

Contact Email:(Required)

Event Information

Name of proposed event:(Required)

Start Date:

End Date:

Time:

Location:

Description of proposed event:(Required)

Is this a first-time event?(Required)

Yes

Please list the specific fund or the area of care where you would like the funds directed to:(Required)

To view the full list of fund designations, click here.

Will the event require insurance?

Yes

If yes, please attach proof of insurance

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 20 MB, Max. files: 2.

Are permits required?

Yes

If yes, please explain:

Please state what percentage (%) of event proceeds will be donated to Atrium Health Foundation:

Please enter a number from 0 to 100.

Projected Revenue:

Projected Expenses:

Ideally expenses should represent 25% or less of the gross income for a fundraiser.

Anticipated Net Revenue:

List other beneficiaries besides Atrium Health Foundation:

Please list any committed sponsors or businesses you plan to approach for support:

Atrium Health Foundation partners with many businesses, so we may ask you to not approach certain companies for support.

Do you wish to utilize an Atrium Health Foundation logo or other Atrium Health facility logo?

Yes

If yes, please explain how and where you wish to utilize the logo and promote the event (print, radio, TV, social media, other)?(Required)

Signature:(Required)

By signing this form, I acknowledge that I have read and agree to follow Atrium Health Foundation's community fundraising guidelines. Please review the full guidelines here.

Date:(Required)