Organization
*
Project or Event
*
Are you a 501c3 Non-Profit organization?
*
Yes
No
Non-Profit 501C3 or Tax ID Number
*
Contact Person
*
Email
*
Phone
*
Mailing Address
*
Address 2
City
*
State
*
Zip Code
*
Which Amberwell organization are you requesting a donation from?
*
Amberwell Atchison
Amberwell Hiawatha
Amberwell Health
What type of donation are you requesting?
*
Funds
Items for Prizes
Logoed Items
Other
Please specify the kind of items you are requesting.
*
Amount Requested
*
Check made out to:
*
What will the funds be used for?
*
How will Amberwell be recognized?
*
Which communities(s) will benefit from the donation?
*
What problem in the community will this event/project help solve?
*
Date donation must be received by
*
-
Month
-
Day
Year
Date
Event Date
*
-
Month
-
Day
Year
Date
Support documents: Ex. Event flyer, donation letter, etc.
Browse Files
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of
Support documents: Ex. Event flyer, donation letter, etc.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
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