Fundraiser Event Proposal

Host Your Own Fundraiser

If you are interested in organizing your own event or participating in an athletic challenge to benefit Samaritans, please complete a the brief event proposal form below to tell us about your plans. After we receive your proposal, a Samaritans representative will follow up with you to discuss your event.

Host Your Own HopeRaiser

Company, Organization, or Individual Conducting the Event/Activity:

First Name

Last Name

Phone

I would like to receive emails from Samaritans, Inc. about events, new programs, and other news.

Yes

I would like to receive text messages from Samaritans, Inc. about events, new programs, and other news.

Yes

Gender Pronouns

Address Information

Address Line 1

Address Line 2

City

State

Postal Code

Country

Type of Event/Activity

Describe Type of Event/Activity:

Name of Event/Activity:

Is This Event/Activity in Honor/Memory of Anyone?

YesNo

Who Are You Honoring/Remembering?

Description of Event and How Funds Will Be Generated (Ticket Sales/Donation Buckets, Raffle, etc.)

Event Date

Event Time

Format example: 9 AM, 9am, 9:00 AM

Event Location

Anticipated Number of Participants

Net Amount Anticipated

Is there a cost to attend your event?

Cost to Attend:

Do not enter currency symbol. Format example: 5.00

How Do You Plan to Promote Your Event?

Samaritans offers a platform to set up your own fundraising page. Are you interested in using this platform?

YesNo

Would you like Samaritans to promote your event via social media?

YesNo

Is this event benefiting other organizations in addition to Samaritans?

YesNo

Do you request a representative from Samaritans to be present at this event?

YesNo

Would you like to receive Samaritans branded items and educational resources for your event?

YesNo

How did you hear about us?

I, the undersigned, hereby grant Samaritans, Inc., its agents, and clients, permission to photograph, audio record, and/or videotape me. I also give Samaritans, Inc. permission to put the finished video, audio, and/or photographs to any legitimate uses they may deem proper and in keeping with the organization’s mission. I understand these materials may be used in marketing and fundraising materials including, but not limited to, A/V productions, event promotions, social media content, web pages, newsletters, email marketing, etc. Further, I relinquish and give Samaritans, Inc., all right, title, and interest I may have in the original finished photographs, negatives, video tapes, film, and electronic image reproductions thereof. My consent is freely given as a public service to Samaritans, without expecting payment.

With any likeness of me:

I prefer that either my first name or full name be used.I prefer that my first name only be used.I prefer that an alias be used.No name can be used.

My preferred alias is:

I understand that I can revoke this release at any time in writing and that the use of any of my photos or other information authorized by this release will cease immediately.

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Contact Information