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UPMC Chautauqua WCA Corporate Events, Contributions, Sponsorships & Participants Request Form

Please Complete Request Form

Event Name: Event Date:
Contact Name:
Contact E-mail:
Contact Phone:
Are you requesting UPMC Chautauqua WCA to be a sponsor of this event? If yes, explain. Yes No
Are you requesting UPMC Chautauqua WCA to participate in this event? If yes, explain. Yes No
Are you requesting UPMC Chautauqua WCA to sponsor or form a team for this event? If yes, explain. Yes No
Are you requesting UPMC Chautauqua WCA to join your event? If yes, explain. Yes No
Are you requesting UPMC Chautauqua WCA to financially support your event? If yes, describe. Yes No N/A
Event Organization
Planning:
At UPMC Chautauqua WCA Off Site (describe)
Event Oversight
Supervision:
UPMC Chautauqua WCA Staff Not UPMC Chautauqua WCA Staff (describe)
Event Location: UPMC Chautauqua WCA Property Offsite Location (describe)
Event Participation: Voluntary/Own Risk Mandatory/Expected (describe)
If UPMC Chautauqua WCA sponsors or participates in your event, does your event possess liability insurance? If yes, explain. Yes No
Event Publicity: UPMC Chautauqua WCA Other (describe)
Additional Information?
If yes, Explain:
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