Memorial Health System
Sponsorship Application
Date of Request:


Date of Event:

Name of Organization:

Organization's Address

Requestor's 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:
 Yes    No

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?
 Yes    No

If yes, provide details:

Was this request made last year?
 Yes    No

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?