Direct Service Registration Form CODEFor internal use only. Type of Community Fundraiser(Required) Donation Drive Fundraising Event What are you tracking?(Required) Gift In-Kind Donation Donation Drive Third Party Fundraising Event Form submitted by:(Required) Fundraiser OverviewEvent Date MM slash DD slash YYYY Event Start Time Hours : Minutes AM PM AM/PM Event End Time Hours : Minutes AM PM AM/PM Drive Start Date MM slash DD slash YYYY Drive End Date MM slash DD slash YYYY Name of Fundraiser Fundraiser DetailsPlease provide a brief description of the fundraiser, including what you plan to collect (i.e. cash, gift cards, essential items).Location of the FundraiserPlease include the name of the venue and street address where your fundraiser will take place.I would like a WC&S representative to attend the event.(Required) Yes No Do you plan on publicizing your fundraiser?(Required) Yes No How will you publicize your fundraiser? Our organization's website Social media Email Print Publications Mailings Other Select AllWhat do we expect to be donated?GIK InformationWhat was donated?(Required) Essential Needs Items Gift Cards Meals Other Gift Date MM slash DD slash YYYY Description of Donation(Required)Estimated Value of Donation Contact InformationContact Name First Last Organization Name Contact Title Contact PhoneContact Email Mailing Address for AcknowledgmentPlease enter the address where the acknowledgment letter for this donation should be sent. Address Line 1 Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NotesCommunity Fundraiser AgreementCommunity Fundraiser AgreementAgreement(Required) I have read the Community Fundraiser Agreement and agree to abide by the guidelines it sets forth.