OIA Community Fundraising Application

Thomas Jefferson University and Jefferson Health Community Fundraising Application

Date Submitted:

This question requires a valid date format of MM/DD/YYYY.

calendar

Name of Organization/er:

*This question is required.

3. Are you a 501(c)(3) organization? *This question is required.

Contact Person & Title:

5. Contact Information *This question is required.

Street Address

Apt/Suite/Office

City

State

Zip

Email Address

Primary Phone Number

Relationship to Jefferson (patient, family/friend of patient, friend, etc.):

8. In addition to the event fundraiser, do you wish to organize an online crowdfunding campaign? *This question is required.

Name of Event/Campaign:

*This question is required.

10.

Description of Event/Campaign:

11. Proceeds will benefit Jefferson's... *This question is required. (e.g. breast cancer research)

When would you like to launch your crowdfunding campaign? This question requires a valid date format of MM/DD/YYYY.

Start Date calendar

What is your campaign's end date? This question requires a valid date format of MM/DD/YYYY.

End Date calendar

12.

Event Date:

This question requires a valid date format of MM/DD/YYYY.

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13.

Start time and end time of event:

14.

Event Location/Address:

15. This event is

16.

Has this event taken place before? If so, when?

Has this campaign taken place before? If so, when?

Will the campaign benefit other organizations?

If yes, what organization?

If yes, percentage of proceeds to Jefferson?

17.

Fundraising Goal (please enter as $ amount):

This question requires a valid number format.