AHSR Sponsorship Request

Organization Name

Organization Phone Number

Area CodePhone Number

Contact Name

First NameLast Name

Contact Person Phone Number

Area CodePhone Number

Email

example@example.com

Mailing Address (where check should be sent if request is approved)

Address

Address Line 2

CityState / Province

Postal / Zip Code

Tax ID #

W9

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To expedite funding, please upload a copy of your organization's W9.

If your request is approved, who should the check be made out to?

Organization name, as it should appear on the check.

What are you requesting?

How much funding are you requesting?

Please provide an explanation of your request (funding amount or items requested, date of event, etc.)

Are you requesting sponsorship for an event?

What date do you need funding or materials by? (Please note, responses take up to 45 days)

Date

Is this a health care or wellness related request?

Which of our Community Health Improvement focus areas does your organization or program address?

Please explain:

Who will benefit from this sponsorship? (Check all that apply.)

How many people are expected to benefit from this sponsorship?

How does your request provide community benefit?

What goals will this sponsorship help you accomplish?

How does this request fit within Adventist Health Sonora's mission?

How does this request enhance Adventist Health Sonora's impact in our community?

Are there any other organizations involved in this sponsorship?

Please list:

Has Adventist Health Sonora ever sponsored or partnered with your organization before?

Please provide any additional information you feel would be helpful or relevant to this request:

Support Documents

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Upload any additional documents that would support your sponsorship request.

Photos

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Upload any photos that tell the story of your organization or sponsorship request.

Do we have your permission to reprint these photos to promote Community Well-being programs at Adventist Health Sonora?

Description of photo(s):

Describe the photo(s)

Participants' Names

List names of people in the photo(s)

By signing below you grant Adventist Health Sonora permission to reprint the photos you have uploaded, and you attest to gaining permission and authorization from each person portrayed inthe photo(s).

By providing your details and clicking "Submit" you agree to:

Receive communications from Adventist Health through email, SMS, text, or calls by an automated telephone dialing system for the purpose of Adventist Health maintaining its relationship with you and providing you information related to services you may be interested in.
Adventist Health collecting and disclosing to third parties personal information and communications for the purpose of fulfilling your inquiries or requests for services or information.