Donation Drive Notification Form

Contact Telephone

Name of Donation Drive

Donation Drive Description

Date of Donation Drive

Donation Drive Location - Street Address



Zip Code

Event Website

Event Facebook

Event Twitter

Donation Drive Frequency

Use of InterAct logo?

If Yes, How Will Logo Be Used?

Request For InterAct Materials?
InterActDomestic ViolenceSexual AssaultOther (please list)

Are You Requesting An InterAct Booth At Event?

Are You Requesting a Representative from InterAct At Event?

Time Speaker Needed

I have read and understood the guidelines and registration and ensure InterAct's name will be properly used, funds will be handled and accounted for in a responsible manner, fundraising will be conducted in a method that is consistent with the public image of InterAct and that all those associated with the event or promotion will act in accordance with all municipal and federal laws. I understand that at anytime InterAct can withdraw its permission if it feels its reputation is at risk or any other liability or challenge arises.