Clinic Fundraiser Request

Interested in having a fundraiser on behalf of the ATI Foundation?

Thank you for your interest in helping to host an event for the ATI Foundation! Please fill out the form below. Someone from the ATI Foundation will be in contact with you if your request is approved to move forward in the process.

Your Contact Information

First Name *

Last Name *

Email *

Office / Clinic Information

Clinic / Office Location The maximum length for the field Clinic / Office Location is 500 characters.

Supervisor's Name The maximum length for the field Supervisor's Name is 500 characters.

Supervisor's Email Address The field Supervisor's Email Address must be an email.

Address The maximum length for the field Address is 500 characters.

Address Line 2 The maximum length for the field Address Line 2 is 500 characters.

Phone The field Phone must be a phone number.

City The maximum length for the field City is 500 characters.

State

Zip Code The field Zip Code must be a number.

Event Information

Please fill out as completely as you are able.

What type of fundraiser do you wish to host?

If you selected "Other", please describe. The maximum length for the field If you selected "Other", please describe. is 500 characters.

Tell us about the event you want to host. The maximum length for the field Tell us about the event you want to host. is 5000 characters.

Date of Event The field Date of Event must be a date.