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Sponsorship Request

*Before submitting request, please review guidelines.

* Date of Request:

* Event/Sponsorship:

* Date of Event:

* Name of Organization:

* Organization's Address:

* Requestors Name(s):

* Requestor's Mailing Address:

* Requestor's Phone Number:

Requestor's Email Address:

* Amount or in-kind contribution request:

If available, what are the sponsorship levels and associated benefits:

* Number of people expected to be reached:

* Timeline/Deadline for decision: (funds must be requested at least 30 days prior to need)

501c (3) number:

* Are you a not-for-profit organization?
YesNo

If yes, provide a copy of your not-for-profit status determination letter.

* Has this group or organization requested any other funding from the Memorial Health System this year?
YesNo

If yes, provide details:

* Was this request made last year?
YesNo

If yes, how much was requested?

* Parameters for involvement (i.e., day-of-event involvement, giveaways provided at event, other related needs):

* Briefly describe the sponsorship or in-kind donation - how it supports the priorities identified in the sponsorship guidelines, etc.

* Describe how funds will be spent:

* How does this request promote health care?

* Limited funds are available for sponsorship requests, so please tell the committee why your request should be considered over the numerous other requests received?

Security Code

Type Security Code

SUBMIT