Proposal to raise funds for the Florey Institute of Neuroscience and Mental Health

Name of Organisation

Contact Person

E-mail

Phone

Address

Brief history of group or individual organising event

Why have you chosen to raise funds for brain/neuroscience research?

Description of event

Date of event

Month Day Year

Location of event

Add website url if relevant

Add any relevant attachments

Select File

What % of proceeds will the Florey receive?

Will any other charity receive part proceeds?

Yes No

Name of other charity

How can we help with your fundraising?

Does a Florey representative need to attend?

Yes No

In submitting this application I, as the organiser of the proposed event, agree to indemnify the Florey Institute of Neuroscience and Mental Health from and against any claims for injuries or damage arising at or from the event that is the subject of this application.

Document revised: December 4th, 2013