ENDORSED EVENTS PLANNING FORM

Thank you for contacting the Moffitt Cancer Center Foundation regarding your upcoming event.
The more we know about your plans, the better we can support your event. Please complete this
planning form, and then return it to the Moffitt Cancer Center Foundation Office. Thank you.

Event Name: __________________________________________________________________

Description of Event: ___________________________________________________________

Contact Person? ________________________Ph. # _______________Ph. # _______________

Mailing Address of Contact _______________________________________________________

_________________________________________Email________________________________

Name of Sponsor/Host___________________________________ Ph. # ___________________

Mailing Address of Sponsor/Host __________________________________________________

_________________________________________Email _______________________________

Date of Event: ___________________________ Rain Date? ____________________________

Time of Event: From _______ a.m./p.m. To _______ a.m./p.m.

Location: _____________________________________________________________________

How many people are expected to attend? ___________________________________________

Who is your target audience? _____________________________________________________

How do you plan to promote the event? _____________________________________________

_____________________________________________________________________________

Describe your plan for handling entry fees, donations, etc: _______________________________

_____________________________________________________________________________

Attach your budget to include: revenues, expenses, and anticipated proceeds.

How much do you expect to donate to Moffitt? $ ________________

Please list other charitable organizations benefiting from this event: _______________________

What prompted you to select Moffitt Cancer Center? ___________________________________

_____________________________________________________________________________
 To ensure that gifts are properly applied/acknowledged, please assist us by designating the
method of your donation(s). Lump sum donations are preferred, however, other arrangements
may be made:

… Lump Sum __________________________________

Name of payer

… Individual Checks __________________________________

Batched or Individually Mailed

… Third Party Payments __________________________________

Name of payer

Important: Third party payments (e.g. Click&Pledge.com, active.com, etc.)

must include event name and/or primary contact for the event. Please request
all checks be made payable to: Moffitt Cancer Center Foundation.

Is there a specific area in the Cancer Center or Research Center you wish to support?

Research Patient Care Education Area of greatest need

Other ___________________________________________________________

Thank you for choosing Moffitt Cancer Center Foundation as your charity of choice.

AGREEMENT OF RESPONSIBILITY:

I/we understand that the H. Lee Moffitt Cancer Center & Research Institute Foundation, Inc. and
its related companies (collectively “Moffitt”) have no liability of any kind for any activity or action
resulting from the efforts of our organization on behalf of Moffitt. I/we agree to allow Moffitt to
approve all written material and promotional items using the Moffitt name or logo, prior to
distribution. I/we agree to indemnify and hold Moffitt harmless for any claims for damages or
injuries resulting from our organizations efforts in support of Moffitt. Additionally, only net
proceeds from the event will be received by Moffitt. No payments or reimbursements will
be made by Moffitt for personal or event-related expenses. If your organization does not
have tax-exempt status, only those payments made directly to Moffitt are tax deductible.

(Signature) (Date)

Please return form to:

Sonia Cerundolo Phone: (813) 745-5709
Moffitt Cancer Center Foundation Fax: (813) 745-5835
12902 Magnolia Drive Email: Sonia.Cerundolo@MOFFITT.org
UTC-FOUND
Tampa, Florida 33612-9416

For Office Use Only: Event approved: Yes No Date: ______ / ______/ ______

Appeal Code: _______________ Appeal Description: ________________________________________ Campaign: _____________________

Fund ID: _____________ Scanned on: ______/______/______ Contact’s Constituent ID/Name: ____________________________________