Blue Crew Event Proposal Form

Contact Information (* required fields)

*Agency Name:
*Contact Name:
*Title:
*Street Address 1:
Street Address 2:
*City:
*State:
*ZIP:
*Email Address:
*Agency Website:
*Phone Number:
*EIN/Tax ID#:
*Agency description & mission:

Event Information

*Describe the duties and responsibilities of the volunteers:

Have we participated in this event previously?: Yes
No

*Date of the project (MM/DD/YYYY):
*Location of project (full address, city, state):

*Time period volunteers are needed:

(Maximum of 6 hours per shift. If multiple shifts are needed, please note below. If each shift is an activity [ex: registration, set up, clean up] please note under additional information.) )

From	Until

From	Until

From	Until

*Total number of volunteers needed:

Will refreshments be provided to volunteers during their shifts?: Yes
No

*Will the members of the Blue Crew be permitted to wear their corporate t-shirts for this project: Yes
No
Dress code requirements, if any:

*Minimum age requirement:
*Prescreening requirements (i.e., child abuse clearance, criminal background check, etc.):
Additional Information:

To ensure your privacy, all information will be sent via a secure connection. Independence Blue Cross will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.