Community Contribution Request Form - Unitypoint Health

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Community Contribution Request Form
Organization: _______________________________________________________________________
Contact Name: ________________________________ Title:_______________________________
Email: ________________________________________ Phone: _____________________________
Address: ______________________________________ City, State, Zip: _____________________
Event / Program Details:
Name of Event / Program: ___________________________________________
Date: ___________
Description: ________________________________________________________________________
_________________________________________________________________________________
How would you describe your event or organization?
Health Organization Community/Civic Activity Education Related Other Non-Profit Organization
Does your organization have 501(c)(3) status with the IRS?
Yes No
In which area will this program help to improve the health of the Greater Peoria area?
Promoting Health Management
Disease Prevention and Support Services  Mental Health Services
General Wellness
Other: ________________________________________________________________
What are the benefits to the community if this request is approved? ____________________________
_________________________________________________________________________________
Target audience and number of people impacted by program:_________________________________
_________________________________________________________________________________
How is the event promoted? ___________________________________________________________
_________________________________________________________________________________
Levels of giving/sponsorship available and forms of recognition at each level: ____________________
_________________________________________________________________________________
Monetary Donation Request:
Requested dollar amount: _______________________ Date Contribution Needed: _______________
Check made payable to: ______________________________________________________________
_____________________
How is the money used?
(% to program, expenses, national organization, etc.)
_________________________________________________________________________________
In-kind Request:
please select appropriate item(s)
 Door prize (estimated dollar amount: _______)  Pens
 Other: ________________________
Artwork Request:
please select appropriate item(s)
 Methodist | Proctor Logo
Format:
JPG EPS
COLOR
BLACK/WHITE
 Methodist | Proctor Ad
Size: __________
COLOR
BLACK/WHITE
Deadline: _________
 Brochures, health education information
 Banner
Deadline: ________________________
FOR OFFICE USE ONLY
Date received: _______
Date reviewed: __________
APPROVED by:__________________________________________ Amount $ _______________________________
Date notified: _________________ Date submitted for payment: ________________________________________
In-kind Donation: _____________________________________________________________________________
W9 received:
YES / NO
n/a
Service Line / Strategic Initiative met: ___________________________________
DECLINED Date notified: __________ Reason: ________________________________________________________

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