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