Date Submitted:

Name of Individual/Organization Planning the Event:

Contact Person:

Phone Number:

Full Address:

Event Name and Type:

Event Date:

Event Time:

Event Location and Full Address:

Please provide a brief description of the event:

Please describe how revenue will be generated (i.e. admission fees, tickets, raffle, proceeds):

Do you require any of the following (please check):

Tax Receipts:YesNo
*If you checked YES then you will need to speak with a representative in the Development Department at Covenant House Michigan to ensure that your event is eligible to issue tax receipts.

Liquor License:YesNo

Gaming License:YesNo

Covenant House Michigan Staff Assistance:YesNo

Please note: For some events and activities it is necessary to take out a liquor or gaming license. However, Covenant House Michigan will NOT take out a liquor or gaming license on behalf of a third-party event.

I, understand Covenant House Michigan reserves the right to approve or deny
this proposal to host a third-party event on behalf of Covenant House Michigan. Pending approval, I
agree the Covenant House Michigan name and logo are registered trademarks and I will follow the
guidelines set for their usage prior to publicizing or holding this event. I agree that a representative of
Covenant House Michigan must approve this proposal and the use of the event’s name prior to the
event. By publicly naming Covenant House Michigan as the beneficiary of my event, I agree to donate
the full amount of the proceeds raised within 60 days of the event date

Signature of Application:
Date:

For Covenant House Michigan Use ONLY
Date Approved: ______/______/______
Approved by: _______________________