Colorado Springs Pediatric Dentistry
Fundraising/Charitable Donations Application

At Colorado Springs Pediatric Dentistry, our staff has the privilege of creating healthy smiles in our community. We are also committed to donating to causes that will help our patients achieve their goals and will have a positive impact on the needs of our community. If your child is looking for a sponsor, needs fundraising assistance or would like us to make a donation to a charitable cause, please complete the following application. Before completing an application, please review the list of causes we currently support, because you may find we already help! Our staff will review the application and determine if we have the ability to provide assistance at this time. If we are able to make a contribution, you will be notified. Thank you very much.

Colorado Springs Pediatric Dentistry supports the following:
• Military Appreciation Day at Cheyenne Mountain Zoo
• Boo at the Zoo
• Teddy Bear Days at Cheyenne Mountain Zoo
• Vista Ridge High School Cheer-leading
• Walk for Compassion
• Centennial 7K Skating Club

Date
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Patient Name
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Date of Birth
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Contact Name
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Contact Phone Number
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Desired Amount of Contribution
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Payable To
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Check Delivery Instructions
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Description of Event/Fundraiser/Sponsorship
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Please explain why this event is important to you.
Your answer
Deadline for submission of funds
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By typing your name below, you are signing this application electronically. You agree your electronic signature is the equivalent of your manual signature on this application.
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