Third Party Fundraiser Application Form

CONTACT INFORMATION:
NAME:
ORGANIZATION: / MAILING ADDRESS:
TELEPHONE:
HOME:

WORK:
CELL: / FAX:
EMAIL ADDRESS:
NAME OF EVENT:

The following information is required by the Alzheimer Society’s Fund Development and Communications Department to evaluate and determine the Society’s involvement

EVENT ORGANIZER INFORMATION

  1. Who is organizing this event? Company Organization Personal
  1. When was your business founded? ______
  1. What is the nature of your business/organization? ______
  1. Website address (if applicable): ______
  1. Please tell us why you are interested in supporting the Alzheimer Society of Nova Scotia through a third party fundraising event.
______
______
______
EVENT INFORMATION
  1. Date of Event: ______
  1. Start Time: ______End Time: ______
  1. Location and Address of Event:
______
______
  1. Describe the nature of the intended event:
______
______
  1. Expected Number of Participants: ______
  1. Target Audience for event: ______

  1. What type of an event are you staging? One Time Event Annual Event

  1. Is this the first year of your event? Yes No
Please indicate any previous beneficiaries: ____________
  1. Who is responsible for the event? ______
  1. How will you be promoting your event?
______
______

  1. Will you be promoting this event: Locally Regionally Provincially Nationally

FINANCIAL INFORMATION
1. How will funds be raised: Pledges Silent Auction Live Auction
Ticket Sales Donations Product Sales
Other (please specify): ______
______
______
2. Projected financial information:
Total Revenue ______Total Expenses ______

3. Will the proceeds be donated to the ASNS only? Yes No
If no, what other charities will be involved? ______

4. Will the proceeds be donated to the ASNS only? Yes No
If yes, please list all organizations being approached:______
______
______
REQUEST FOR ASNS STAFF/VOLUNTEER INVOLVEMENT
  1. What are your expectations of the ASNS?
Volunteers: Yes No If Yes, How many? ______Hours? ______
Required Tasks? ______
Public Speaker: Yes No Please provide details: ______
Rep at Event: Yes No Please provide details: ______
Please note, ASNS involvement in your event will be subject to availability and based on specific event details.
  1. Would you like the ASNS Logo and Forget-Me-Not Symbol for promotional use?

Yes No If Yes, on what type of materials? ______
______
Please note, ASNS must first approve the use of our logos on ALL materials.

TERMS AND CONDITIONS

  1. All projects must be ethical and compatible with the Alzheimer Society of Nova Scotia’s mission and values. The public perception of the activity must not be injurious to the Society.
  1. The event should be financially sound in the opinion of the ASNS and all reviewing this application. The Society reserves the right to withhold the use of its name and logo’s from any event that does not meet the evaluation criteria.
  1. All funds must be received by the Society no later than 30 days after the day of the event.
  1. The ASNS must give approval to ALL materials that use the Alzheimer Society of Nova Scotia name and/or logo prior to publication and/or distribution (including websites).
  1. The involvement of ASNS staff, volunteers and resources must be agreed upon prior to the commencement of the event. Decisions around the Society’s involvement will be determined based on factors such as availability, size and nature of the event, etc.
  1. The ASNS must assume no legal or financial liability associated with the event.

The Alzheimer Society of Nova Scotia respects your privacy and will never sell, trade, or loan your information to any other organization. Your information will be used only for follow-up contacts, and to process and recognize your donations. We disclose your information only to our own employees and agents, and only to accomplish the purposes listed above. By providing this information you consent to our collection of the information.

By signing this document, I agree to the collection of the preceding information to allow the ASNS to evaluate the event and the level of the Society’s involvement. This information may be disclosed to employees and agents of the ASNS as necessary to perform this evaluation and any requested activities. I am aware that this information will be kept for 7 years by the ASNS. I also agree to the Terms and Conditions outlined above and have read and agree to the Third Party Event Policy.

______

Signature of Event OrganizerDate

______

Signature of ASNS RepresentativeDate

Fax forms to: (902) 422-7971 or Mail to: 6009 Quinpool Road, Suite 300, Halifax, NS B3K 5J7