Fundraiser/Event Application
*MUST BE SUBMITTED 60 DAYS IN ADVANCE OF EVENT*
EVENT NAME/OR TYPE: ______________________________________
DATE OF APPLICATION: ______________________________________
ORGANIZATION/COMPANY INFORMATION
ORGANIZATION/COMPANY NAME: _____________________________________________
ESTABLISHED: _________________________ MEMBERSHIP:________________________
(Number of individuals, or size of mailing list)
ORGANIZATION /COMPANY ADDRESS:
___________________________________________________________________________
(Street, Suite, Floor, City, State, Zip)
PHONE: ____________________________
FAX:__________________________________
WEB ADDRESS: (if applicable) __________________________________________________
ORGANIZATION/COMPANY DESCRIPTION: (Brief summary about mission of organization or company background)
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________________________________________________________
_______________________________________________________________________
CONTACT INFORMATION:
NAME: ______________________________________________________________________
AFFILIATION WITH ORGANIZATION/COMPANY/EVENT:______________________________
ADDRESS: (If different from organization/company’s)
__________________________________________________________________________
(Street, Suite, Floor, City, State, Zip)
PHONE: _____________________________
FAX: _______________________________
EMAIL: ____________________________________________________________________
FUNDRAISER/EVENT INFORMATION:
DESCRIPTION ABOUT FUNDRAISER/EVENT: (Brief summary and/or goals of event, or product information.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
_____________________________________________________
FUNDRAISER DATE: __________/___________ EVENT HOURS: ________-________
(Day of the Week/Date)
(Time open and close to guests)
EXPECTED ATTENDANCE/PROJECTED SALES: ___________
CORPORATE SUPPORT FOR EVENT: (Sponsors, media, in-kind donations)
YES
NO
IF YES, PLEASE LIST:
_______________________________________________________________________
CELEBRITY PARTICIPATION: (Spokesperson, host, donor, guest)
YES
NO
IF YES, PLEASE LIST:
______________________________________________________________________
TARGET AUDIENCE: (gender, age, race, breast cancer survivors, education level, languages spoken other than
English, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________
PLEASE PROVIDE A BRIEF DESCRIPTION ABOUT YOUR METHOD FOR RAISING FUNDS:
(Silent
auction, ticket sales, drawing, raffle, product sales, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
_________________________________________________________________
HOW WILL YOU PROMOTE THE EVENT: (media, radio, television, print ads, brochures, flyers, etc.) Be specific.
___________________________________________________________________________________
_______________________________________________________________________
HOW MUCH MONEY DO YOU ANTICIPATE DONATING TO KOMEN GRAND RAPIDS 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.)
___________________________________________________________________________________
_______________________________________________________________________
WILL ANY OTHER CHARITABLE ORGANIZATIONS BENEFIT FROM THIS EVENT? IF SO, PLEASE
NAME AND DESCRIBE TO WHAT EXTENT THEY WILL BENEFIT:
___________________________________________________________________________________
_______________________________________________________________________
VENUE INFORMATION:
ADDRESS:
_____________________________________________________________________________
(Facility name)
_____________________________________________________________________________
(Street, floor, and/or suite)
_____________________________________________________________________________
(city, state, zip)
Between _______ and_______________
(Avenue/Street)
VENUE Contact:
___________________________________Phone:____________________________ (Name of
the contact you are working with at venue and phone number)
MATERIALS:
Educational Materials (such as Breast Self-Exam Cards, mammography coin cards, etc.) are available
for your event, free of charge. Please indicate your needed quantity and we will forward you an
assortment of literature. If you have specific questions about the breast health literature that we offer,
please contact our Komen Office at (616) 752-8262.
QUANTITY: __________________________________
PLEASE ALLOW 2-3 WEEKS FROM YOUR SUBMISSION DATE FOR OUR RESPONSE.
THANK YOU!
Please send completed form to:
info@komenmichigan.org
Or mail to:
3949 Sparks Drive Southeast, Suite 100
Grand Rapids, MI 49546
Questions?
Contact Tanya Horan at 616-752-8262 x2014