Community Benefit Sponsorship Application
The mission of Adventist Health is to live God’s love by inspiring health, wholeness, and hope. Our community benefit focus is aligned with the current Community Health Needs Assessment (CHNA) and Community Health Implementation Strategy (CHIS).
Organization Name
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Applicant
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Is your organization a 501c3?
*
Yes
No
Federal Tax ID #
*
Sponsorship type:
*
Sponsorship
In kind donation
Other
What areas of focus does this grant apply? (choose all that apply)
*
Access to Care
Health Conditions
Mental Health
Other
Please provide a detailed explanation of your request.
*
Sponsorship Amount Request
*
Have we sponsored this event in the past?
*
Yes
No
How does the work of your non-profit organization align with Adventist Health Simi Valley’s mission and focus areas listed above?
*
How does your request provide a community benefit?
*
Describe how your request advances health equity.
*
What goals will this sponsorship help your organization accomplish?
*
Event Date
*
-
Month
-
Day
Year
Date
Event Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Expected event attendance
*
What does this sponsorship include? (choose all that apply)
*
Event booth
Logo on website
Program advertising
Admission Tickets
Other
Please upload support documents including sponsorship letter request, event flyer, and W9 form.
*
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