Community Organized Fundraiser Application

Contact Information

Event Organizer/Primary Contact

Organization

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Tell us why you would like to fundraise for St. Charles Foundation and/or St. Charles Health System

Event Details

Event Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Event Date(s)

Select the single date of event

Enter the starting date of the event

Enter the ending date of the event

Time of Event

Estimated number of attendees

Event Description

Please provide a brief description of the event.

Event website

Will St. Charles Foundation be the sole beneficiary?

Yes

Please list other beneficiary(s) and percentage(s) of proceeds to each, including St. Charles Foundation

Agreement

Did you read the full Community Organized Fundraising Rules and Guidelines?

Read the Community Organized Fundraising Rules and Guidelines here.

Yes

Initial or sign in agreement

Financial

How will you raise funds (select all that apply)

Virtual Fundraising Page (VFP)

Ticket/admission sales

Sponsorship

Auction (live and/or silent)

Donation

Games of chance (casino games, bingo, raffle, etc.)

Other

What good(s) or service(s) will donors receive as part of admission? What is the value of the good(s) or service(s)?

Have you acquired all necessary licensing from the Oregon Department of Justice for your game of chance fundraiser?

Yes

What is your fundraising goal?

Will you use proceeds from the event to fund expenses?

Yes

How much do you anticipate in expenses?

How much do you anticipate your net income to be?

Do you anticipate making one donation after the event, or multiple?

When is your anticipated donation submission date?

Where do you want the donations to be directed?

St. Charles Foundation's General Fund

An unrestricted donation that allows St. Charles Foundation to determine and fulfill the areas of greatest need at St. Charles Health System and/or St. Charles Foundation.

Cancer Services

Including but not limited to providing financial support to St. Charles Cancer Center for programs, patient support, screenings, research funding, etc.

Pediatrics

Including, but not limited to, supporting the NICU, pediatric department, children's programs, specialized pediatric and neonatal medical screenings and equipment.

Scholarships

Including, but not limited to, providing financial assistance to St. Charles employees through continuing education, certificates and degrees.

Need help deciding

General

Do you plan to use St. Charles' name and/or logo?

Yes

Would you like to provide complimentary tickets/admissions for a St. Charles Foundation and/or St. Charles Health System representative to attend the event?

Based on staffing availability and tickets must be provided a minimum of 12 weeks in advance of event.

Yes

How many tickets/admissions are you providing?

What is included with ticket/admission?

Will you be serving alcohol at your event?

Yes

Have you contacted OLCC for licensing and permit requirements?

yes

Do you require any permits, licensing or certificates of insurance for your event?

Yes

The fundraising event or appeal organizer/sponsor/organization agrees to indemnify, refund and hold St. Charles Foundation and St. Charles Health System harmless against and in respect of any and all claims, demands, losses, costs, expenses, obligations, liabilities damages, recoveries and deficiencies, including interests, penalties and reasonable attorney’s fees that shall be incurred or suffered by St. Charles Foundation and St. Charles Health System which arise, result from or relate to the fundraising appeal, the organizer/sponsor/organization’s performance of its agreement as specified in the guidelines and Community Organized Fundraising Application.

Initial

I hereby acknowledge that I have read and understand the Rules and Guidelines as outlined in St. Charles Foundation’s Community Organized Fundraising Toolkit. I agree to comply with these Rules and Guidelines to the best of my ability.

Please use a mouse, stylus or index finger to sign the box below.

Date signed