Community Events/Materials Request Form

Thank you for your interest in including Donate Life in your event. Please complete the below information and you will be contacted shortly. Please allow a minimum two weeks for staffing and/or shipping of materials. If you have any questions, please feel free to contact Kathleen Hostert, Community Programs Supervisor at khostert@onelegacy.org or 213-356-5208.

Event Name: (examples: 'Pan-American 5K and Festival'   'Taft High School Classroom Presentation'   'St. Joseph Hospital Skills Day')

Event Location: (examples: 'Whittier Narrows Park'   'Taft High School'   'St. Joseph Hospital')

Location Detail: (examples: 'South soccer fields'   'Room E4 - Health Class'   'Cafeteria')

Event Info

Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:

Site Contact Name: Site Contact Phone: Site Contact Email:

Start Date: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Additional Dates:

Report Time:Start Time: End Time:

Event Type: Other Speaker Table Materials Only Audience: General Public Students Hospital Staff Other Ethnic Focus: Multicultural Asian African American Hispanic Caucasian Other

Brief Event Description:

Parking Instructions: How Many Volunteers Needed:

Materials (Please specify quantity needed)

English Brochures:	Spanish Brochures:
African American Brochures:	Asian Brochures:
Bookmarks:	Paycheck Stuffers:
Brochure Inserts (English):	Brochure Inserts (Spanish):
Posters (11 x 17):	Candy (250/bag):
Key Chains:	Pens: Pencils:
Stickers (200/roll):	Lapel Pins:
Magnets:	Bracelets:

Ship To

Full Name:Phone Number: Email:

Address: City: State: Zip: