Community Vitality Funding

Personal Information

First name *

Last name *

Organization

501c(3)?

Street address *

City *

State *

Zip *

E-mail address *

Phone *

Details of Request

Purpose *

Please indicate the type of support you are requesting:

Financial support $

In-kind donation

Health screenings

Donation usage *

Please indicate whether any of the following opportunities are provided to sponsors:

Sponsor opportunities

Event / Program details *

Number of people expected to attend:

Please indicate the primary audience(s) served (check all that apply):

Please list other current sponsors

Others contacted

Deadline *

Month

Day

Year

Please indicate your desired deadline for a confirmed sponsorship or donation.

Information in the form of flyers and sponsorship levels is appreciated. After submitting the form, please email them to Julie Jank.

Allegiance Health

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