event registration form

name*

First NameLast Name

phone number*

Please enter a valid phone number.

email*

example@example.com

address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your connection to Dayton Children's Hospital?

event name*

event type*

if other, please specify

event date*

Date

rain date (if applicable)

Date

event start time*

Hour Minutes

AM/PM Option

event end time*

Hour Minutes

AM/PM Option

event location*

Name

Street Address

CityState

Zip Code

Describe how the event will raise funds (ticket sales, pledges, sponsorship, auction, etc.) *

Has this event taken place before? *

if yes, when?

Do you intend to use Dayton Children's name and logo? *

Dayton Children’s requires all event materials (posters, t-shirts, etc.) that include the hospital name or logo to be reviewed and approved by Dayton Children’s before production. Please allow five business days for review.

proceeds to benefit

if other, please specify

estimated donation*

will other charitable organizations benefit from this event?

if yes, please list the names of these organizations and describe the extent to which they will benefit below.

I have read and agree to the terms of Dayton Children's Hospital Foundation's third party event guidelines*

Guidelines: I understand the completion of this form does not mean, and may not be construed to mean, that the proposed event has been approved by Dayton Children’s Hospital. The event’s sponsor must receive confirmation indicating approval of the event from the hospital before any publicity may be released. Dayton Children’s reserves the right to request additional information about a proposed event or its sponsors before considering approval of the event. The event sponsor(s) agree to indemnify and hold Dayton Children’s Hospital harmless from any claims of any nature arising from or related to, the proposed event. Furthermore, understand that nothing in this proposal shall be construed to authorize the sponsoring organization or any representative thereof to act as an agent of Dayton Children’s Hospital.