Background Information

Name of Group/Company Planning Event *

Contact Person *

Contact Person's Title *

Mailing Address *

Email *

Telephone *

Website

Fax

Please indicate the category that best describes your group * Corporate School Service Club Family Grateful Patient Other

Event/Fundraising Information

Name of proposed event *

Briefly describe the event and how funds will be raised *

What inspired the decision for you or your group to fundraise for WellSpan Health? *

Date(s) *

Time(s) *

Location *

Address *

Are you soliciting sponsors for your event? * Yes No

Will other charitable organizations benefit from this initiative? * Yes No

Is a license required for this event? * Yes No

The person requesting the event must obtain any necessary permits, licenses or in their own name or the name of their organization. Please submit copies prior to event.

Promotional Materials

All logos of WellSpan Health and its entities are registered trademarks, the use of which is restricted. In keeping with industry standards, WellSpan Health will only permit use of its logo to those organizations that have a substantial, established relationship with the organization. In those cases, any use of the WellSpan Health logo or name for the proposed event must be approved by WellSpan Health prior to being printed and/or released.
Please note that while you may possess a copy of the logo from a previous initiative, WellSpan Health must approve any subsequent usage of the logo.
Printed materials and other information should state the “Proceeds will support the beneficiary”

Public Relations Information

Will you be promoting your event? * Yes No

Would you like to have WellSpan Health Staff/Board of Directors participate in your event? * Yes No

Which of the following will you be using to publicize your event? * Internal promotion such as newsletters Posters/Flyers Advertisements Public Service Announcements Other

What is the estimated duration of the promotional activities? *

What is your estimated net revenue for this event? *

TERMS AND CONDITIONS

I/We have read the Event Guidelines and, if this proposed activity is approved by WellSpan Health and WellSpan Philanthropy, we agree to abide by all conditions set forth in the event guidelines and/or outlines specifically for this proposed activity.

Specifically, I/We agree that:

• The named “person in charge” of proposed activity has the authority to enter into this agreement. WellSpan Health and WellSpan Philanthropy are not responsible for any debts or costs incurred as a result of this activity. I/We agree to hold WellSpan Philanthropy and WellSpan Health harmless against the action of any creditors. In addition, the applicant agrees to appropriately handle and safeguard all funds received, and in a timely manner, deposit the proceeds intended for the WellSpan Health beneficiary and transfer those funds to the appropriate WellSpan Philanthropy office for processing.
• Any printed materials, press releases, etc. mentioning WellSpan Philanthropy or WellSpan Health will be submitted for approval prior to use. I/We further understand that approval of proposed activity does not constitute permission to use WellSpan Philanthropy or WellSpan Health logos in any materials, as such use is restricted to entity-sponsored events.

Terms accepted by:

Signature of Applicant *