Event Request Form "*" indicates required fields Step 1 of 3 33% Organization DetailsType of Event*Stewardship/CultivationCMNAlumniInternal FundraisingCommunity PartnerCommunity AssociateCFR Event AttendanceOtherOrganization Name*Contact Person* First Last Requestors Name* First Last Mailing Address* Street Address 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 Email* Phone Number*Requesting Organization/Department*Employee Type* UF Health Shands University of Florida If you are a Shands employee, have you read: Core Policy 04.009 HR Policy 104 Main Contact(s)If different than event requestor listed above. Use the (+) to add additional contacts as needed. Make sure to include the primary DO associated with the event.Contact NamePhoneEmail Add RemoveAdvancement Team Members AttendingUse the (+) to add additional names as needed. Add Remove- Event/Fundraiser Main Contact*Use the (+) to add additional contacts as needed.Contact NamePhoneEmail Add RemoveDecision Makers/Key Stakeholders/Committee Members*Use the (+) to add additional contacts as needed.NameTitle Add Remove Event DetailsEvent Name*Name of Event/Program*Event TypeHospital TourKickoff/RetreatCMN EventPartner EventStewardship EventHave you obtained approval from your unit leadership?* Yes No Do you have an event date set?* Yes Not yet, but I have a preferred timeframe No Event Date MM slash DD slash YYYY Event Start Time Hours : Minutes AM PM AM/PM Event End Time Hours : Minutes AM PM AM/PM Event Description*Event/Program Description*Will the event require out of town travel? Yes No Will an over night stay be required? Yes Possibly No Location of Event/ProgramAddress of Event Location Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are there other beneficiaries besides an entity of UF Health? No Yes Event Objective*Who are the event attendees?Anticipated AttendancePlease enter a number greater than or equal to 1.Event Attendance By Invitation Only Open to the Public Have you ever hosted this event before? Yes No If yes, what was the outcome?Area of Interest/FundArea of Interest/SupportWill you be requesting an online giving page? Yes No Will you be creating an online giving page (GoFundMe, Fundly, etc.)? Yes No Are you requesting any senior leadership involvement?*(Motew, Hunt, Green, Holmes, Long) If yes, you will be notified on the status of your request following a review. If confirmed, you will be contacted to coordinate any additional information for briefing leadership. Yes No Which leader(s) are you requesting?*Check all that apply. Stephen J. Motew, MD, MHA, FACS, President and System Chief Executive Officer, UF Health Jennifer L. Hunt, MD, MEd, Interim Dean, UF College of Medicine Patrick L. Green, FACHE, Senior Vice President and Northeast Florida Regional President, UF Health JacksonvilleChoice Michael D. Holmes, MSA, UF Health Senior Vice President and Greater Gainesville Regional President Heather B. Long, MSN, BA, RN, Senior Vice President and Central Florida Regional President Date you need confirmation by:* MM slash DD slash YYYY Leadership Arrival Time* Hours : Minutes AM PM AM/PM Leadership Departure Time* Hours : Minutes AM PM AM/PM Dress code (if known):*Enter unknown if there is no set dress codeKey Prospects:*Enter N/A if none identified. Use the (+) to add more names as needed. Add RemoveOther UF Leadership Attending:*Ex: President, Provost, other UF Dean, etc. Enter N/A if none attending. Use the (+) to add more names as needed. Add RemoveLeadership(s) Role(s)*Ex: serve as MC, participate in check presentation picture, give remarks, etc…Benefit to UF Health*Other Leadership/VIP InvolvementUse the (+) to add more names as needed.NameSpeaker? Yes or No Add RemoveWill CMN Ambassadors be involved in the event? Yes No Unknown at this time Name(s) of CMN Ambassador(s)Use the (+) to add additional names as needed. Add RemoveDoes the event meet any of the following factors?Check all that apply. The event involves... ... senior UF Health and/or UF leadership. (VP/Dean level or higher) ... a major gift announcement. ... a fundraising component. ... a media component. ... a groundbreaking, ribbon-cutting, dedication, or naming. ... high-profile community involvement. Support Being Requested (describe):Level of support requested from Stewardship Event Coordinator: Full management. No organization staff available to work on event. Partial management. Organization staff available to do legwork and participate, but need support on portions of the event. Day of support. No event organization required. No support needed. Will you be requesting support from the Stewardship Event Coordinator? Yes, day of only Yes, planning and day of No support needed Event Request FormMax. file size: 125 MB. Fiscal DetailsExpense Plan*Check all that apply Fundraising Department Budget Expense PlanCheck all that apply CMN Funds Partner Funds Other Expense Plan*Check all that apply Department/Division DO Budget Stewardship Budget Donor Funded Other Fundraising Activities (check all that apply): Ticket Sales Registration Auction Raffle Sponsorship General Donations In-Kind Donations (examples: toys, soft goods, food, etc.) % of Sales Other Estimated ContributionAnticipated ExpensesMust submit a detailed draft budget with proposal.VenueCustodialCateringPrinted MaterialsPlaques, Awards, etc.Entertainment: Stage, Lighting, D.J., etc.OtherUntitled
