Name *

First Name

Last Name

Phone *

(###)

###

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Event Date *

MM

DD

YYYY

I agree that the CACNA1A Foundation must approve my event and use of the logo prior to promoting the event. By publicly naming the CACNA1A Foundation as the recipient of the proceeds of my event, I agree to donate the net proceeds within 14 days of the event. I agree that the CACNA1A Foundation has the right to rescind permission for any event inconsistent with its mission and values. The CACNA1A Foundation does not provide insurance coverage for DIY events. *

I agree