Contact and Participation Information

Thank you for your interest in Make a Difference May! Please fill out the below information, and our team will reach out about next steps.

*Required field.

Business Name

Prefix

First Name

Last Name

Phone Number

Business Address

City

State

Zip Code

Fundraising Goal

How will you fundraise? Select all that apply.

Point-of-sale campaign

Portion of or percentage-of-sales donation

Donation at checkout (for customers)

Roundup at the register (for customers)

Other

If you selected "Other," please describe.

Duration of Promotion :

Number of Participating Locations·

Will promotion include any online locations?

Yes

Describe Fundraising Activity

If you have been working with a Children's Mercy contact, please list their name here.

Would you be interested in a tour of Children’s Mercy Adele Hall Campus?

Yes

If yes, how many people would attend the tour?