Sponsorship Funding Request Form Organization Name Organization Phone Number Contact Name Please enter a contact name. Contact Person Phone Number E-mail This isn't a valid email address. Please enter your email address. Street Address Please enter your address. Street Address Line 2 City Please enter your city. State / Province Please enter your state or province. Postal / Zip Code Please enter your postal code. Tax ID # Please enter your tax ID. W9 What are you requesting? What are you requesting? Funding Promotional Items / Giveaways Room Space Other What are you requesting? Please provide an explanation of your request (funding amount, promotional items, age group/audience, date of room use, other, etc.). Please provide more information. Are you requesting sponsorship for an event? Yes No Are you requesting sponsorship for an event? What Date? What date do you need materials or others by? (Please note: responses take up to 45 days) What date do you need materials or others by? Is this a healthcare or wellness related request? Yes No Is this a healthcare or wellness related request? Which priority area does your event or request align with? Select One Access to Care Access to Quality Primary Care Health Services & Prescription Medicines Access to Affordable, Healthy Food Access to Mental, Behavioral and Substance Abuse Services Access to Specialty Care Health Education and Literacy Access to Transportation and Mobility How does your request provide community benefit? Please provide community benefit information. What goals will this sponsorship help you accomplish? Please provide sponsorship goals. How does this request support Adventist Health and Rideout's mission? How does this request support Rideout Health's mission? How does this request enhance Adventist Health and Rideout visibility/impact in our community? How does this request enhance Rideout Health visibility/impact in our community? Are there any other organizations involved in this sponsorship? Yes No Are there any other organizations involved in this sponsorship? Who? Has Rideout Health ever sponsored or partnered with your organization before? Yes No Has Rideout Health ever sponsored or partnered with your organization before? Please provide any additional information you feel would be helpful/relevant to this request? Please provide any additional information Support Documents Submit
