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. Type of fundraising page: *This question is required.

Name of campaign:

*This question is required.

10.

Description of campaign:

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

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

Start Date calendar

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

End Date calendar

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

15.

Will the campaign benefit other organizations?

16.

If yes, what organization?

17.

If yes, percentage of proceeds to Jefferson?

18.

Fundraising Goal (please enter as $ amount):

This question requires a valid number format.