Sponsorship Funding Request Form
Organization Name
*
Organization Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tax ID #
*
W-9 Form
*
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What are you requesting?
*
Funding
Promotional Items/Giveaways
Room Space
Other
Please provide an explanation of your request (funding amount, promotional items, age group/audience, date of room use, other, etc.).
*
Are you requesting sponsorship for an event?
*
Yes
No
What is the date of your event?
-
Month
-
Day
Year
Date
What date do you need materials or others by? (Please note: responses take up to 45 days)
-
Month
-
Day
Year
Date
Is this a healthcare or wellness related request?
*
Yes
No
Which priority area does your event or request align with?
*
Access to care
Access to quality primary care health services and prescription medicines
Access to affordable, healthy food
Access to mental, behavioral and substance abuse services
Access to specialty care
Health education and literacy
Access to transportation and mobility
How does your request provide community benefit?
*
What goals will this sponsorship help you accomplish?
*
How does this request support Adventist Health and Rideout's mission?
*
How does this request enhance Adventist Health and Rideout's visibility/impact in our area?
*
Are there any other organizations involved in this sponsorship?
*
Yes
No
Who?
Has Adventist Health and Rideout ever sponsored or partnered with your organization before?
*
Yes
No
Please provide any additional information you feel would be helpful or relevant to this request.
*
Support Documents
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