Event Details Thank you for organizing an event to support NYU Langone! Please submit the event details below. If you have any questions, please contact communitygiving@nyulangone.org. Host InformationTitleMr.Ms.Mrs.MissName First Last Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please tell us about your relationship with NYU Langone Health.AlumCurrent NYU Langone employeeFamily/friend of former or current patientFormer or current patientSupporterOtherEvent InformationEvent Name Date MM slash DD slash YYYY Rain date, if applicable MM slash DD slash YYYY Venue Name Venue Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Event TypeCocktail Party/ GalaGolfOtherWas this event held previously?YesNoFundraisingFundraising goal amount ($) Estimate Expenses ($) Estimated Donations ($) Event PromotionHow do you plan to fundraise for your event? Ticket sales Outright donation Sponsorships Raffles Other How will you promote your event? Social media Email Invitation Flyers Other Is this event invitation only or open to the public?Invitation onlyOpen to the publicEvent AgreementPlease read and confirm your consent to the policy and community event agreement by checking the box below.(Required) I agree to the privacy policy.Event Host • You agree to be responsible for the operation of the event, including all costs and expenses associated with the event, and to conduct the event in a safe, lawful, and professional manner. • You may use the name of NYU Langone Health only to inform the public about your event. • You are responsible for providing NYU Langone Health with the names and addresses of donors who make cash donations (if they wish to be acknowledged by NYU Langone Health) and a full description of any items donated for silent/ live auctions. • Post-event recaps need to be submitted to NYU Langone Health at CommunityGiving@nyulangone.org for evaluation with a complete accounting of funds collected and related expenses. • Approval for the event is specific to dates and locations listed on the pre-event form. Annual events must submit a new form each year. • Under no circumstances may an event associate itself with a tobacco-related company or product or any other vendor that would not be an appropriate representation of NYU Langone Health. Event Planning • You are responsible for the planning, marketing, operation, and cost of the event. • You agree that out-of-pocket costs for the event will not exceed more than 20% of total funds raised. • You agree to submit to NYU Langone Health drafts of all the event materials for review by NYU Langone Health to CommunityGiving@nyulangone.org. • You agree to conduct the event in a safe manner and comply with all applicable laws. For example, drawings, sweepstakes, sales of products by businesses with a promise to donate a portion of the proceeds, and other similar activities are legally regulated and may require permits and registrations. You also might be required to collect and remit sales tax in certain circumstances on some auction sales. • If the host chooses to serve alcohol, they are solely responsible for ensuring compliance with all laws and regulations, and assume all liability for any form of negligence that may arise from the consumption of alcohol. • If applicable, the host must obtain its own liability insurance to cover the event. NYU Langone Health will not insure the event and the organizer must obtain all insurance, including premise liability and worker’s compensation. • You agree to pay over the proceeds from the event to NYU Langone Health. • You will keep accurate financial records of the event and make them available to NYU Langone Health. • You agree that all event promotional materials will include the following information in a clear and uniform format: (i) any flat donation (e.g., the exact percentage of the retail purchase price or the fixed dollar amount per purchase) that will be donated to NYU Langone Health, (ii) any limits (maximum or minimum) on the total amount to be donated to NYU Langone Health, (iii) whether any consumer action is required to trigger a donation, and (iv) the start and end dates of the event. You shall be responsible for handling all monies in connection with the event. NYU Langone Health Abilities To support your event, NYU Langone Health will: • Provide gift receipts for direct contributions made to NYU Langone Health; • Provide informational brochures or fact sheets about our programs and services for the event; • Authorize use of NYU Langone’s name upon review and approval of the event materials; • Provide written tax receipts to donors who make direct contributions to NYU Langone Health or make contributions through NYU Langone’s online giving platform dedicated to your event. Unfortunately, NYU Langone Health is unable to: • Release names of patients, former patients, donors, trustees, volunteers, employees, physicians or mailing lists for any purposes including event invitations; • Offer funding or reimbursement for expenses related to the event; • Create or provide event invitations; • Permit the use of the NYU Langone logo; • Promote the event through NYU Langone publications and media outlets including social media and email; • Take responsibility for selling tickets to the event and/or promoting the event; Guarantee staff, volunteer or patient/family attendance at the event; • Provide auction items or create and maintain an online silent auction including storage and safeguarding of auction items. NYU Langone Health reserves the right to: • Decline any proposed event. • Approve all uses of its name and revoke its permission at any time at its sole discretion. • Return donations if the way that the donation was received unlawfully or otherwise unacceptable to NYU Langone Health (e.g. donations from gambling events). • Use any videos or photographs sent by you for its general marketing purposes without cost, credit, or attribution to the organizer. You agree that sending us your videos and photos sent to us constitutes permission for NYU Langone Health to use them. • Use event information through all media and online channels, including but not limited to Facebook, Twitter, and the philanthropic giving site.
