EmailMe Form - Fundraise to End Lupus Now in the SE Application

Applicant's Name *

First Last

Company or Organization

Applicant's Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Applicant's Phone *

### - ### - ####

Applicant's Email *

Who is organizing this event? *

Individual (if different from applicant please list Organizer's name in the other box below)

Company/Organization (please list above)

Other

Event or Company/Organization Web Site (if applicable)

What goals do you plan to accomplish with your event? *

Why would you like to support the Lupus Foundation of America, Southeast Region through your community event? *

Name of Event *

Date of Event *

MM / DD / YYYY

Start Time of Event *

HH : MM AM/PM

End Time of Event *

HH : MM AM/PM

Venue Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Venue Contact *

Venue Contact Phone

### - ### - ####

Venue Contact Email *

Target Audience for Event *

Please describe your anticipated audience (examples: lupus patients, general public, average age, ethnicity/race)

Expected Number of Participants *

What is the frequency of this event? *

One Time Event

Annual Event

Is this the first year of your event? *

Yes

No

If no, who was your previous beneficiary?

Will alcohol be served at the event? *

Yes

No

Will this event promote any sort of product or company? *

Yes

No

If yes, please list the products or companies to be promoted.

Please describe how you will be promoting the event. *

If applicable, how will funds be raised at this event? (Please check all that apply)

What percentage of proceeds do you plan to contribute to LFA Southeast Region (please post this percentage on all promotional materials including website per BBB guidelines)? *

Will the Lupus Foundation of America, Southeast Region be the sole beneficiary of this event? *

Yes

No

N/A (for awareness events only)

If no, please list other organizations that will also benefit from this event.

Are you approaching sponsors for this event? *

Yes

No

If yes, please list companies or organizations being solicited for sponsorship.

I understand that if I am referring to the Lupus Foundation of America in any event promotional materials or online, I will not use LFA's logo. When referring to the Lupus Foundation of America, I will say "X% of Proceeds will benefit the Lupus Foundation of America". *

Yes

No

IF AVAILABLE, would you like an organization representative to attend this event? *

Yes

No

NOTE: Organization representation is based on availability of staff and trained volunteer ambassadors; participation cannot be guaranteed. In addition, please note that organization representatives are not health care providers.

If yes, please describe what role our organization representative will have in your event.

Other information you think would be helpful for us to know about your event.

*

I agree to fill out a post-event form.

By digitally signing below, you understand that the Lupus Foundation of America, Southeast Region reserves the right to approve or deny this request to host a third-party fundraising event on behalf of the Lupus Foundation of America. Pending approval, you agree that the Lupus Foundation of America name and logo are registered trademarks. You also agree that the Lupus Foundation of America, Southeast Region must approve this request prior to publicizing or holding your event. By publicly naming the Lupus Foundation of America, Southeast Region as a beneficiary of your event, you agree to donate the agreed amount listed in this application no later than 15 calendar days after the event and make your budget and actuals available per request. The Region will only provide receipts if payment is made to the Lupus Foundation of America directly by check, cash or online donation. *

Clear

Sign your name by clicking and holding your mouse in the blank space to draw out your signature.