| Contact |
| Contact Information |
| Title: | |
| First Name:* | |
| Last Name:* | |
| Address Line 1:* | |
| Address Line 2: | |
| City:* | |
| Province: | |
| State: | |
| ZIP/Postal Code:* | |
| Phone:* | |
| Country: | |
| Fax: | |
| Cell Phone: | |
| Email:* | |
|
| Mail to this Address? |
| Name of Event:* | |
| Date and Time of Event:* | |
| Location:* | |
| How many years has this event been held?:* | |
| Details/description of this event::* | |
| Will other charitable organizations also benefit from this Fundraiser or promotion?:* |
Yes
No
|
| Please list them::* | |
| Is there a specific area of the hospital to which you would like to designate the proceeds?:* |
Yes
No
|
| Please list where you would like the funds to go:* | |
| Pending availability, would you like representation from the Foundation and/or hospital at your event?:* |
Yes
No
|
| Would you like to present a cheque to the Grand River Hospital Foundation representatives?:* |
Yes
No
|
| Estimated donation to the Grand River Hospital Foundation:* |
Up to $500
$500 - $2,500
$2,500 - $10,000
Greater than $10,000
|
| May the Foundation recognize your organization or company's efforts in our donor recognition program?:* |
Yes
No
|
| Do you plan to use any of the following names and/or logos in your printed materials and plublicity?:* |
Yes
No
|
| Grand River Hospital (logo and/or name):* |
Yes
No
|
| Grand River Regional Cancer Centre (logo and/or name):* |
Yes
No
|
| Grand River Hospital Foundation (logo and/or name):* |
Yes
No
|
| How do you plan to promote your fundraiser?:* | |
| How? (ie. print, tv, radio):* | |
