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Community Support Request

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Community Support Request

For best results, using Google Chrome is recommended to complete the form.

Request Information

Type of Support Requested (Check all that apply)*!

Exhibitor
Giveaways
Health Presentation
Health Screening
Monetary Donation
Program
Sponsorship
Advertising
Meeting Space
Other

General Contact Information

Request Date

Event Name (if applicable)!

Name of Organization*!

Contact Person*!

Phone (Work)!

Phone (Mobile)!

Email Address*!

Address*!

City*!

State*!

Zip*!

Organization Information

Is your organization a tax-exempt organization?*!

Yes
No

Organization's Website

Organization's Mission (500 Character Limit)

Organization's Counties Served *!

Christian
Logan
Macon
Morgan
Sangamon
Other

Community Support Information

Describe Request (such as target audience, number of people to be served, how this support will be used, etc.) (500 Character Limit)* !

Does your initiative support one of Memorial’s identified community health needs? (economic disparities, mental health, access to health, obesity, substance use, lung health, cancers, or equity/diversity/inclusion)*!

Yes
No

Memorial Health Information

Is anyone at Memorial Health on your organization's board or involved with this initiative?!

Yes
No
Unknown

Will Memorial Health receive any publicity or recognition for this donation?

Yes
No
Unknown

Has Memorial Health provided support for your organization in the past?

Yes
No
Unknown

If Memorial Health support is provided, the use of those resources are to be restricted to the purpose stated in this online Community Support Request form. This includes any funding designated for IRS Community Benefit-eligible purposes. Do you accept this restriction of funding?*!

I accept
I do not accept

Submit

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