Fundraising Registration Form

*Contact Name

Person to contact who is coordinating the event or activity

*Phone

Mobile Phone (if different)

Group / Club or Organisation Name

*Address

*Suburb/Town/City

State

*Postcode

*Email

*Name of proposed event or activity

Event Location

Address of venue

*Date event starts

Time event starts (if known)

Date event finishes

Brief description of event or activity

How will fund be raised?

Is the event supporting any other charity?

yes

no

What support do you require from QEI?

Please be as detailed as possible.

Event promotion approval

yes

no

Please specify if you agree to allow QEI to promote or publish details of your event.

Agreement

I agree

I agree to act in a professional manner in conducting the fundraising activity and uphold the integrity and values of the Queensland Eye Institute. I also accept my obligation to remit the funds raised to the Queensland Eye Institute within 14 days of the event conclusion. You will be contacted by a fundraising team member with the full terms and conditions for fundraising on behalf of QEI. Prior to publicising or conducting any event you must obtain Queensland Eye Institute's approval.

Queensland Eye Institute

Personal Details

Event Details