Donation Request Form

First Name

Last Name

Email

Name of Organization

Are you a current Clarkson Eyecare patient? Yes   No

How did you hear about us? (Select all that apply.)

• TV
• Radio
• Direct Mail Piece
• Newspaper
• Billboard
• Cardinals Game
• Health Fair
• Online Ad
• Social Media
• Web Search
• Other

What type of donation would you like? - Please Select - Event Sponsorship Health Fair Medical Need Monetary Donation Other

Please attach any applicable file (flyer for your event, etc.)*
*Must be in PDF format.

Date of Event

How many attendees/participants? - Please Select - Less than 50 50 to 200 201 to 500 more than 500

Comments and/or Questions