Growing Smiles Pediatric Dentistry :: Donation Request Form

Below you will find the donation request form.

Please complete the entire form and email any supporting information, including flyers, brochures or websites, describing the event to info@wegrowsmiles.com. Please note that while we review every request for a donation, completion of the form below will not guarantee funding. Thank you!

You may also download a PDF copy of the Donation Request Form and email or mail to our office with all supporting documentation included.

Today's Date:

Your Name

Email Address

Telephone Number

Address (Street, City, State Zip Code)

Name of Organization Requesting Donation

Tax Id Number for Organization

This Organization is (Choose One): This Organization is (Choose One): Educational or Scholastic Related Non-Profit/Charitable (Must include 501(c) documentation) Community Organization University of Kansas Organization Fundraising for local individual Other

Please explain the reason this donation is being requested:

Where will the proceeds from the event/project be used?

Approximately how many individuals will benefit from this donation?

Donation Amount Requested ($):

Date Donation is Needed:

Additional Comments:

13 + 3 =