PFLAG EUGENE/SPRINGFIELD
P.O. BOX 11137
EUGENE, OR 97440
686-2280
GSA DONATION REQUEST FORM
Parents, Families and Friends of Lesbians and Gays (PFLAG) promotes the health and well-being of gay, lesbian, bisexual and transgender persons, their families and friends through: support, to cope with an adverse society; education, to enlighten an ill-informed public; and advocacy, to end discrimination and to secure equal rights. PFLAG provides an opportunity for dialogue about sexual orientation and gender identity, and acts to create a society that is healthy and respectful of human diversity.
DONATION PHILOSOPHY:
We are pleased to help support Gay Straight Alliances in Lane County.
What is the name of your school? _______________________________________________
What donation (amount are you requesting from PFLAG? __________________________________
How do you plan to use this donation? (Be specific):___________________________________
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______________________________________________________________________
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[attach sheet(s) if necessary]
What time period do these plans cover? (i.e. school year, fiscal year etc.): ____________________
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Are you willing to make a commitment to report back to PFLAG at the end of this time period on how our donation was used and the results of your project? ___yes ___no
Name of your contact person: ______________________________________________________
Phone number:___________________________________________________________
Name of Faculty advisory: ________________________________________________________
School Address: _________________________________________________________
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Phone: ________________________________________________________________
Email: _________________________________________________________________
