Requesting Agency:
Agency name:
Contacted_person:
Address:
Phone:
Director:
Number of paid staff: Number of volunteer staff:
Services provided:
Population served:
Years of operation in Wichita:
Requested Donation:
Date of request: Date donation is needed by:
Monetary donation amount in $: Funds to be used for:
Volunteers needed for multiple day project:

Volunteers needed for single day project:

Donated items needed for:
Funding Resources:
Currently receiving United Way funds? Yes No
Additional funding resources:

Please complete this form and click the send button at the bottom of the page, or print and fill out this form and mail your request to: Attn: Outreach Board, University Congressional Church 9209 E. 29th St. N. Wichita, KS 67226

For internal use only: Contacted by phone on: ____________ by ____________
Contacted by person on: ____________ by ____________
Request considered by board on: ____________ Action taken: ____________