Red, White, and Blue Crew – Corporate Volunteer Program

Event Proposal Form

Your Contact Information (* required fields)

*Agency Name: « Required
*Contact Name: « Required
*Title: « Required
*Street Address 1: « Required
Street Address 2:
*City: « Required
*State: « Required
*Zip: « Required
*E-mail Address: « Required
*Agency Website: « Required
*Phone Number: « Required
*EIN/Tax ID#: « Required
*Agency description & mission: « Required

Event Information

*Describe volunteer opportunity (requested activity): « Required

Have we participated in this event previously?: Yes
No

*Duration of the project (choose one): Ongoing volunteer opportunity
One-time volunteer project « Required

*Date of the project (mm/dd/yyyy): « Required
*Location of project (full address, city, state): « Required

*Time period volunteers are needed:

(Maximum of 5 hours per shift. If multiple shifts required please note below.)

From	Until

From	Until

From	Until

« Required
*Number of volunteers needed per shift: « Required

Will refreshments be provided to volunteers during their shifts?: Yes
No

*Will the members of the Blue Crew be permitted to wear their corporate t-shirts for this project: Yes
No « Required

Dress code requirements, if any:

*Minimum age requirement: « Required
*Prescreening requirements (i.e., child abuse clearance, criminal background check, etc.): « Required
Additional Information:

To ensure your privacy, all information will be sent via a secure connection. AmeriHealth will not disclose any personal information to outside persons or entities without your written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.