Young Philanthropists Application

Young Philanthropist Application

About the Applicant

Young Philanthropist's First Name(Required)

Young Philanthropist's Last Name(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Young Philanthropist's Birthday(Required)

Is the Young Philanthropist a former patient of Levine Children's Hospital or another department within Atrium Health?

Yes

If yes, please provide the facility or department name

Please describe in brief detail the nature of the Young Philanthropist's fundraising events or activities benefiting Atrium Health, including the event/campaign description, date(s), and venue (if applicable).

This applications is submitted by:

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

I am the Young Philanthropist's:(Required)

Other

CAPTCHA