[Imported Form] Apply For Sponsorship

Name*

First NameLast Name

Title/Position*

Are you an LVHN colleague?

YesNo

Organization Name*

Organization Address*

Street Address

Street Address Line 2

CityState

Postal / Zip CodeCountry

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

Current LVHN Affiliations/Involvement

(E.g. LVHN board representation, volunteer involvement, clinical or non-clinical shared programs or other collaboration.)

Name of the Event/Initiative*

Date of Event/Start Date of Initiative*

MonthDayYear

Deadline Date for Commitment/Material Submission

MonthDayYear

Estimated Reach/Attendance

Sponsorship Form*

Please upload your organization’s sponsorship information, including details on available opportunities, pricing, artwork specifications, etc.

W-9*

Please upload your organization’s W-9

Payment link

Please provide a link to accept payment if available (ie. PayPal)

Which of these community health priorities does your request fall under (if any)?

Behavioral health (education, prevention, collaboration, innovation, substance use disorder, decreasing stigma, suicide prevention)Access to care for vulnerable populations (homelessness, veterans, uninsured or underinsured individuals, those who lack reliable transportation)Inclusion and diversity (language, disabilities, etc.)Health promotion and preventionSocial determinants of health (i.e. food access, obesity, housing & poverty)Other

Has LVHN supported this Event/Initiative in the past?*

YesNoUnknown

If yes, please briefly describe:*

Why do you feel that LVHN should invest in this initiative? What mission or business goal does this activity support?*

Would you be willing to attend or volunteer at this event and/or recruit participants?*

YesNo

Additional Comments