REGISTRATION FORM & GUIDELINES FOR ... - Austin Health

- 2 –6. Type of Event7. Venue and/or address of function8. Brief description of the event/function9. Purpose for which Funds are being raised10. Event/Function promotionPlease ConfirmWe agree to forward samples of all promotional materials andcorrespondence including all electronic and possible media releasesstating Austin Health's name (or other Austin Health Institution names) toAustin Health for approval, before publishing, promoting or distributingmaterials.YES / NO

- 3 -11. Austin Health is the sole beneficiary of monies raised from the eventIf No, please indicate other beneficiariesYES / NO12. The net proceeds of the Event/Function will be donated to AustinHealthYES / NOIf No, please state what part orcalculation of how the funds will be distributed13. Further commentsPLEASE NOTE:Austin Health will not take any responsibility for expenses incurred by organisations or individualsraising money to benefit Austin Health, unless specifically authorised in writing.Under the Privacy Act Austin Health cannot provide any lists of volunteers or patients, donors etcAustin Health respects your privacy and will not give your details to a third party. Your contact detailswill only be included on our secure database, for you to receive receipts and updates on Austin Health,including quarterly newsletters.Signed: .......………………………………………………………………..APPLICANTDate: ………………………Approved: ………………………………………………………………….DIRECTOR OF FUNDRAISINGDate: ………………...…….Please Return to:Melissa CrampFundraising DepartmentAustin HealthLocked Bag 25HEIDELBERG VIC 3084Phone: 9496 4158Fax: 9496 5160Email: melissa.cramp@austin.org.auWebsite: www.austin.org.auwww.oliviaappeal.com