Sponsorships/Speaker Request Form

Requestor Information

Full name:

Phone Number:

E-Mail Address:

Mailing Address:

Best time and method to contact you:

Request Type (Check all that apply):

Financial sponsorship and/or donation of materials
Participation in a community event by hospital employees, physicians or volunteers
Speaker for a community group or event
Other

Other Request Type:

Request Details

Name of group or organization making the request:

Name of event:

Date of event:

Location of event:

What is the purpose/goal of this event or request:

Brief description of event:

Type of support or involvement requested:

Who will be attending (target audience):

Number of participants expected:

Are there special issues such as language, culture, or literacy that we should be aware of?

Yes
No

If yes, please explain special issues:

Other organizations who are expected to participate:

How will this event or sponsorship be publicized or promoted and by whom:

Are promotional opportunities available for St. Joseph Healthcare ? (i.e., ads in program, informational booth, etc.):

Yes
No

If yes, please list promotional opportunities:

Is there a stipend or honorarium, and if so, how much:

Additional details:

Approved request needed by:

Is your organization not-for-profit?

YesNo

If yes, what is your Tax ID number?

Amount of financial sponsorship requested:

Date financial support needed:

Description of materials requested:

Date materials needed:

Comments

Please let us know any other comments that may be helpful in the review of your request:

Enter the numbers and letters shown above here:

St. Joseph Hospital is a member of Covenant Health Systems

Sponsorships/Speaker Request Form