Organization Name*

Organization Address*

Organization Type*
 Schools, Colleges, and Education Related Organizations Health, Wellness, and Related Organizations Youth and Family Services Police, Fire, and Military Organizations Youth Soccer Other

Point of Contact Name*

Point of Contact Title*

Point of Contact Phone Number*

Point of Contact Email*

Event Name*

Event Date*

Event Address*

Street Address*

City*

State*

Postal / Zip Code*

Event Website

Donation Need-By Date*

Additional Comments / Donation Details (To include nature of event, how funds raised will be used, etc.)

Attach a File (event brochure, flyer, etc.)