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Snapshot of the Word file:"PHOENIX CHILDREN’S HOSPITAL_ APPLICATION FOR FUNDRAISING/EVENT/PROMOTIONFORUNM CHILDREN’S HOSPITALRevised: A".doc
APPLICATION FOR FUNDRAISING/EVENT/PROMOTION FOR UNM CHILDREN’S HOSPITAL Revised: August 2005Any persons and/or organizations desiring to conduct an event or promotion that involves the use of the name "UNM Children's Hospital" for fundraising and/or publicity efforts must complete this Application and sign the accompanying Guidelines Agreement. Written approval from the UNM Hospitals Executive Director of Development must be received in advance of beginning of any such fundraising or publicity efforts. Fax or mail the completed Application and Guidelines Agreement to: Executive Director of Development UNM Hospital’s Development Office 700 Lomas N.E., Suite 100 Albuquerque, NM 87102 Phone: (505) 277-5685 Fax: (505) 277-5687 If any assistance is needed in the process of completing either the Application or Guideline Agreement, please contact the UNM Hospitals Development Office at (505) 277-5685. Thank you for your interest and support! UNM Children’s Hospital Fundraising Application Form A. SPONSOR INFORMATION1. Name of sponsoring Individual, Business, School, Group or Organization: ______________________ 2. Contact person for this Fundraiser: 3. Mailing Address:
5. Fax: 6. E-mail: ___________________________________________________________________________ B. PROMOTION INFORMATION1. Name of promotion: 2. Description of promotion: 3. Location(s): 4. Date(s) and time(s): 5. Date promotion will end: (Donations should be given/disbursed to UNM Children’s Hospital within 30 days of this date). 6. Please list the major source of funds (i.e. ticket sales, auction, percentage of sales, etc. Note: any proposed raffle needs to be discussed in detail with UNM CH):
8. If you advertise or publicize this promotion, who will be handling these tasks? 9. Who is your target audience: 10. Please attach approvals by local authorities and evidence of insurance. C. FINANCIAL INFORMATION 1. Please list below any and all categories and amounts of revenue you expect to receive and their sources. Category Amount each Quantity Total Source Examples: T-shirts $5 per shirt 100 $500 From sale Refreshments N/A $1000 Applicant will secure sponsor Tickets $5 per ticket 1000 $5000 From admission 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. _________________________________________________________________ TOTAL REVENUE:$ 2. Please list below any and all categories and amounts of expenses you expect to incur and the source from which they are to be paid. Category Amount each Quantity Total Source Examples: T-shirts $3 per shirt $300 Applicant will fund Refreshments N/A $1000 Applicant will secure sponsor Prizes $5 per prize $50 To be deducted from gross proceeds Tickets $ .10 per ticket 1000 $100 Printing cost to be deducted from gross proceeds 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.___________________________________________________________________ TOTAL EXPENSES:$ C. USE OF FUNDS1. Please indicate area where donation should be applied: _____Children’s Miracle Network Fund_____ Pediatric HIV/AIDS_____ Hospice _____Pavilion Fund_____ Medical equipment_____ Children’s Psychiatric Ctr. _____Pete’s Playground_____ Child Life_____ Adult Psychiatric Ctr. _____ Pediatric Oncology Fund_____Indigent Care Fund_____ Trauma _____ Lifeguard _____ Other fund (please specify) ________________________ 2. Anticipated date of your donation: 3. Approximate net proceeds to be contributed to UNM Children’s Hospital:$ _____________________ D. ADVERTISING/PROMOTION1. Will there be use of UNM Children’s Hospital name and/or logo throughout the promotion? (circle) yes no 2. In what promotional materials (newspaper ad, radio ad, in-store signs, etc.) will you use UNM Children’s Hospital name? ____________________________________________________ |