Gift in Kind Form | UAMS Be a Part of the Cure Walk

Organization or Individual Name(Required)

Preferred Name to Display on Promotional Materials(Required)

Primary Contact Person(Required)

First Last

Email(Required)

Primary Phone Number

Alternate Phone Number

Correspondence Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gift In-Kind Type(Required)

Physical Product(s)

Service (to be Redeemed at Later Date)

Gift Card

Description of Gift In-Kind Donation

Fair Market Value

Gift in Kind Delivery

Please contact me to arrange pick-up or drop-off of my gift(s) in-kind.

My Gift In-Kind will be mailed/shipped

My gift(s) in-kind will be delivered to the Winthrop P. Rockefeller Cancer Institute before Thursday, April 18th.

Vendor Table

My organization is interested in hosting a Vendor Table on the War Memorial Stadium field during the event. Please send more details and the Vendor Table Registration Form to the information provided above.

My organization will forgo the opportunity to host a Vendor Table on the War Memorial Stadium field during the event.

Envelopes and parcels may be mailed to:

Winthrop P. Rockefeller Cancer Institute
Attention: Daniel Frazier
4301 West Markham Street
Slot #623-2
Little Rock, AR 72205

All gift in-kind products and vouchers must be received by Friday, April 18th, 2024. Waiver and Photo Release Agreement

To ensure your gift-in-kind is properly acknowledged and receipted, please return this form no later than Friday, April 18th, 2024 to:

Daniel Frazier
DFrazier@uams.edu
501-686-5872