Kesem Together
Organization Name
Applicant Name
Email Address
Phone Number
Role/ Title
Are you looking for a recurring program (monthly, bi-monthly, quarterly), or a one-time program?
One-Time
Monthly
Bi-Monthly
Quarterly
What is your ideal duration?
1-2 Hours
2-4 Hours
4-6 Hours
6+ Hours
Other
Anticipated Age Ranges
1-5
5-10
10-14
14-18
Other: Duration
Anticipated Number of Children
Do you plan to have parents participate?
Yes
No
Unsure
Do you have any available supplies (arts & crafts, sports equipment, etc.)
Do you have an ideal date for this event?
Who is the primary contact for logistics?
Who is the primary contact the day-of?
What is your organization or company's budget for each event?
The budget will determine how many children we are able to serve
What is your primary goal of hosting Kesem Together programs?
Childcare during an event or conference
Regular programming for kids impacted by a parent's cancer
Parent Programming
Other
Other: Goal
What is the location of the event space?
How many individuals can the event space hold?
Would you like activities primarily based on fun, connection through shared cancer experience, or a mixture of both?
Fun
Connection through shared cancer experience
Mixture of Both
Is there event parking near by?
Free
Paid
Unknown
Is there Wi-Fi available in the event space?
Yes
No
Unsure
Does the event space have access to audio/visual equipment?
Yes
No
Unsure
Is the event space shared, or we will be the only group using it?
Shared
Exclusive Access
Unsure
Do you have participation waivers available?
Yes
No
Unsure
Is the location indoor/outdoors?
How do you plan on promoting or advertising this event to your constituents?
Contact Information
Kesem TogetherKesem Together