Please submit one application per event. If you have multiple events you must submit separate applications.
Name of Requesting Organization: *
Primary Contact Information
Name: *
Title: *
Phone: *
Address: *
City: *
State: *
Zip: *
Fax:
Email: *
Cell Phone / Other:
Name of Event or Initiative: *
Date of Event or Initiative: *
Amount Requested: *
Type of Event * Gala or Dinner Event Golf Outing Walk Annual Fund Year-round Partnership Other (Specify)
Alignment With Providence Strategic Focus Area * (Select primary area of focus.) Health/Wellness or Improving Health Access Cardiovascular Health Women's Health Orthopaedics Health Care Workforce Development Community or Neighborhood Development
Provide your organization's mission and vision:
Describe the initiative for which you're requesting support (purpose and outcomes):
Describe success and evaluation metrics for this initiative:
How does this initiative align with Providence Hospitals' mission?
What communities (in terms of geographic area and number of people) does your organization serve? How will your initiative reach them?
Providence embraces ongoing partnerships that reach into the community. Describe the benefits to Providence of partnering with you on this initiative. In addition to this initiative, what programs does your organization have that would provide ongoing opportunities to collaborate with Providence and its staff?
Does your organization have board representation by any Providence employee or member of our medical staff? If yes, please explain.
Please list other prospective and existing sponsors approached and amounts requested from each. Is this application a part of a series of requests from your organization? If yes, please list.
Please provide any additional information you would like to be considered as part of your application.
You may attach a document below: (Word, PDF, RTF, TXT) File Name:
