Loan of the Huntington's Disease Memorial Quilt (hereafter called the Quilt) will be made on a first come first choice basis. Please include this application, describing your event and display site, as well as your goals in displaying the Quilt. Include as much detail as possible in order to provide the Hunt-Dis HD Quilt Project with the most complete information. E-Mail the application to jemiller@tampabay.rr.com or mail it along with your deposit to Hunt-Dis HD Memorial Quilt Project ...
c/o Jean E.
Miller
1835 Pine
Cone Circle
Clearwater,
FL 33760
Requestor: ___________________________________________________________________________
Organization: _________________________________________________________________________
* Responsible Party Name: _____________________________________________________________
Title/Position
:__________________________________________________________________________
Mailing Address
:______________________________________________________________________
Phone: _______________________________________________________________________________
Fax:___________________________________________________________________________________
Email:
________________________________________________________________________________
Display Dates:
_______________________________________________________________________
Name of Event:
_______________________________________________________________________
Estimated Attendance: _______________________________________________________________
Open To Public:
___Yes ___No
* It will be the Responsible Party's duty to insure the Quilt is properly taken care of and protected during the loan period.
Display
Site and Shipping Information
The Quilt
should be shipped to the venue in which it will be displayed. The Quilt
will be shipped to you C.O.D. insured. Your organization is responsible
for returning the Quilt in it's original shipping container and is required
to pay shipment and insurance costs. Phase I of the Quilt weighs approximately
15 pounds. One section is 10' by 10' and is suitable for hanging. The other
section is smaller and can be displayed on a tabletop. At no time should
the quilt be laid on the floor. All displays must be indoors and the area
regularly monitored. The Quilt is to be locked up or otherwise protected
when display hosts or building security is not available.
Display site: _____________________________________________________________________
Shipping Site (if different) _________________________________________________________
Contact Person:
_________________________________________________________________
Phone Number:
___________________________________________________________________
Email:
_____________________________________________________________________________
Display
Fee:
A deposit
of $75.00 is due with your application to cover cleaning expenses, if any.
If the Quilt does not require cleaning upon it's return, this deposit will
be returned to you. Enclosed: $75.00 check made payable to The Hunt-Dis
HD Quilt Project
Media
and Maintenance Donations
A suggested
Media Package and a Maintenance Donation sheet will be provided to you
upon acceptance of your application. All donations received for the Maintenance
of the Quilt while will be returned with the Quilt.
Signature: _______________________________________________
Date _______________________________________________________