Organization Contact Information (mailing address, phone & email) *
Your answer
Tax Status *
Your answer
Tax ID Number *
Your answer
Purpose: Choose one category that best describes your cause. *
Amount Requested or description of in-kind donation. Please note if there are various sponsorship packages. *
Your answer
Have you received a monetary donation from this hospital in the past? *
If so, how much and when?
Your answer
List your major contributors to this event/cause: *
Your answer
Are any other fundraisers planned (or have taken place this fiscal year)? Please list: *
Your answer
If this request is for a specific event, list the date(s) of the event.
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Is there a possibility to have an informational booth at the event? Will you provide a canopy, table or chairs?
Your answer
Does the sponsorship or donation include any advertising or promotional efforts? If so, please list below. *
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Please list any deadlines that should be considered.
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Are any hospital employees actively involved in your organization? *
If yes, please list their names and functions within your organization.
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How many people will benefit directly from your efforts? *
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What is your organization's primary focus? *
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If other local organizations provide similar services, indicate how your program is unique.
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How exactly will the funds you are applying for be used? (List local projects or economic benefits. Please be specific.) *
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How will this project address local community needs? *
Your answer
Additional Comments
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Please send additional information (i.e. sponsorship packets) to natoyah.swift@CanyonVistaMedicalCenter.com
Signature to certify the information above is correct and that all funds, if approved, will be used solely as described above. Please type your name and date to agree. *