Community Sponsorship Application

Every month a Sponsorship Allocation Committee representing Providence Regional Medical Center reviews sponsorship requests according to stated guidelines. Sponsorship requests must be received two months before the scheduled event or program in order to receive consideration.

In addition to submitting the form below, if you have supporting documents you would like considered as part of your application, please email them separately as attachments to Cheri Russum.

Today's date:	Decision needed by:
Contact name:	Organization:
Phone:	Email:
Address:	City:
State:	Zip:
Sponsoring organization is a non-profit: yes no	Proceeds will benefit a non-profit organization: yes no
Amount requested: $	Date contribution is needed:
Event/activity name:	Event/activity date:

Describe the event or activity:

Describe the demographics of the people who will participate in this event/activity:

How many people will attend this event/activity:

Describe the demographics of the people who will be served by this event/activity:

How many people will be served or will benefit from this event/activity?

What is the goal of this event/activity?

How will this event/activity improve the healthcare status, or provide for the needs of the poor and vulnerable of our community?

Will results be measured, and if so, how?

Will the sponsorship include visibility for Providence Regional Medical Center as a community supporter, and if so, how?

What other sponsors have confirmed their participation?

What other sponsors will be approached for participation?

What other information should we consider in evaluating this request?