GIVE65 Admin Portal U.S.

* Required field
Application for Participation
Completion of this application should take no longer than 20 minutes. Because you are unable to save the application, we encourage you to start and complete the application in one sitting. You will have the best results if you fill out this application on a desktop computer rather than a mobile device.
Point of Contact

Please enter the name and contact information for the person responsible for your profile. This person will receive communication and GIVE65, including confirmation of your organization’s ability to participate.

* Primary Contact First Name
* Primary Contact Last Name
Primary Contact Title
* Primary Contact Email
* Primary Phone Number
* Organization NameTo Appear on Leaderboard
* Address 1
Address 2
* City
* State
* Zip Code
* EIN (Federal Tax ID Number)
* Please select one category that best describes your organization's mission
Organizational Details
* Operating Budget
In what year was your organization established?
Mission Statement
* How many seniors are served annually by your organization?
* What option best describes your organization?
* What percent of the clients your organization serves are 65 years of age or older?
* Please upload a list of your current Board members.
No file is currently uploaded.
Upload File
Additional Information
* How did you hear about us?
Other (please specify)
If a Home Instead Senior Care franchise office encouraged you to participate in GIVE65, please indicate the name and email of your contact below.
* Name
* Email
About your GIVE65 fundraising project
* What is the name of the program or service you will feature on the GIVE65 platform?
* Please describe the program or service you will feature on the GIVE65 platform and the impact it is having on seniors. If it is new, please share your hopes and goals for the program or service.
Acknowledgements and Disclaimers

Click here to download and read through the Terms of Use and Privacy Policy

* I have read and agree to the Terms and Liability.
* I certify that the applicant organization is registered with the U.S. Department of Treasury, Section 501(c)(3), Internal Revenue Code, and has a current tax-exempt status.