Organization Name:





Contact Name:


Email Address:

Website Address:

Requested Walk Location:

1. Is your organization a 501 (c) 3 non-profit? Yes No
2. When was the nonprofit founded (i.e. YYYY)?

3. What is your mission?

4. What specific services does your organization provide? To what population?

5a. Our organization is Local (serving area in one county)
Regional (multi-county)
National (local chapter)
5b. Number (approximate) of people served yearly  
5c. Number of employees: Full-time Part-time
5d. Number of active volunteers  
6. Do any of your employees have fundraising experience? Yes No
If yes, please list names and titles:

7a. Do you have a board of directors? Yes No
7b. Are any of your board members Highmark Inc. employees? Yes No
If yes, please list names:

8. Please list your current fundraising events and dates for these events.

9. Have you received grants or sponsorship dollars from Highmark Inc. in the last year? Yes No
10. Does your organization carry Highmark Inc. insurance? Yes No
11. Is anyone in your organization related to a Highmark Inc. employee? Yes No
If yes, please list Highmark Inc. employee and relation to organization employee:

12. Do you have a staff person who can be the main contact and attend all meetings? Yes No

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