Community Partnership Application
Sponsorship type
*
Annual Partnership
Single Event
In Kind Donation
Mobile Unit
I am requesting the mobile clinic for the following services:
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Point of Care Services
A1C
Hemoglobin
Glucose
Urinalysis
Pregnancy test
Weight / Height
Blood pressure / Pulse
Vaccinations
COVID-19 Vaccines
Pfizer adult (1st, 2nd + booster)
Pfizer kids (1st + 2nd)
Moderna (1st, 2nd + booster)
Health Education
Diabetes
Hypertension
Nutrition
Medication
COVID
Pre-natal
Other
Focus area
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Access to Care
Obesity/Healthy Eating/Diabetes
Mental Health
Economic Security/Homelessness
Maternal and Infant Health
Geographical target area
Please be as specific as possible
Event Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event date
-
Month
-
Day
Year
Date
Event start time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event end time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event age range
Zip code(s)
Requested sponsorship amount
*
In-kind request
Event information
Where will sponsored funds go to:
Explain how does the work of your organization align with Adventist Health’s mission and focus areas listed above
*
Will this sponsorship request include events and activities?
Yes
No
Please describe any events and activities that will be included
Does this sponsorship request include requests for Adventist Health to provide goods or services, like education, health screenings or in kind donations?
*
Yes
No
Please describe any goods or services that Adventist Health would be expected to provide
*
Have we sponsored previously?
*
Yes
No
Please upload any event fliers, sponsorship request documents
Browse Files
Cancel
of
Name of Applicant
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Organizational Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please verify that you are human
*
Submit
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