Community Benefit Sponsorship Request: AHMC, AHUV, AHHM

Name of Applicant*

First NameLast Name

Organization Name:*

Phone Number*

Area CodePhone Number

Email*

example@example.com

Name of individual authorized to sign a funding agreement on behalf of the organization:*

Organizational Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please describe your request:*

Requested sponsorship amount:*

When is a response needed?*

Date

Sponsorship type:*

One-time funding requestAnnual sponsorshipIn kind donationOther

While we understand the focus of many organizations is on single events, we will prioritize annual sponsorships. Each organization can only be awarded one sponsorship per year. If you plan on requesting support multiple events, please apply for the annual sponsorship.

Focus area*

Mental healthSubstance abuseDomestic abuseOther

How does the work of your organization align with Adventist Health's mission and focus areas?*

The mission of Adventist Health is to live God’s love by inspiring health, wholeness and hope. Our community benefit focus is on improving community health outcomes for mental health substance use and domestic abuse.

Define geographic target area by zip code to be served by this funding request.*

Describe how your request advances health equity.*

Describe your organization’s capacity to successfully implement the program/project.*

Describe your organization's sustainability plan.*

Have you received a sponsorship from Adventist Health in the past?*

YesNo

If yes, please list the date(s)*

Is this sponsorship request for an event that includes event tickets?*

YesNo

If yes, how many tickets are included?*

If yes, what is the dollar value of each ticket?*

Does this sponsorship request include requests for Adventist Health to provide goods or services such as giveaways, education, health screenings or in-kind donations?*

YesNo

If yes, please explain:*

Please upload a completed W-9, any event fliers and/or sponsorship request documents*

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