Hospice Helpers Application

Name: Hospice & Palliative Care Buffalo
Address: 225 Como Park Blvd., Buffalo, 14227, 1
Telephone: 716-686-8077

Name of Organization or Group

Name of Individual(s) in charge *

Mailing Address (city, state, zip code) *

Email *

Phone Number *

Name of Event

Date & Time of Event

Location of Event

Event is

Open to Public Invitation Only

Ticket Price

Has this event taken place before? *

Yes No

Will this be an annual event? *

Yes No Possibly

Briefly describe the event *

Estimated revenue from event *

Estimated expenses *

Estimated contribution to Hospice Foundation *

After expenses, what percentage of the net proceeds will go to the Hospice Foundation?

If the proceeds will be split, please list additional beneficiaries

Do you require someone from the Hospice Foundation to speak at your event? *

Yes No

Will you require any Hospice Volunteers?

Yes No

If yes, how many?

Volunteer shift times

Volunteer job description

Do you plan to use the Hospice Foundation logo in any promotional materials? *

Yes No

Will you require any Hospice brochures? *

Yes No

If yes, how many?

Will you require any Hospice brochures?

Yes No

How will your event be promoted?

Will you be alerting the media?

Yes No

If yes, please list media outlets

Your Electronic Signature (write name in box) is confirmation that you have read and agreed to the Hospice Helpers Guidelines *

Date *

Keep up with the latest Hospice & Palliative Care Buffalo news and events!

Milch - Mitchell Campus
225 Como Park Boulevard
Buffalo, NY 14227

716-686-8077