Sponsorship / Donation Request Form

Organization Details
Company/Organization Name
Name*
First Last
Phone*
Email*
Is your organization tax exempt?*
- Yes
- No
Tax ID Number
Our vision is creating a healthier southwest Wisconsin, and our top criteria for supporting programs is whether it provides a DIRECT health benefit. Describe how your organization or this program addresses community health needs in southwest Wisconsin.*
Event / Project Details
Name of Event/Project
Date of Event/Project
Date Format: MM slash DD slash YYYY
Location of Event/Project
Please include the address details of the event/project below.

Street Address City State / Province / Region ZIP / Postal Code
Description of Event/Project
Describe in detail the nature of your event or sponsorship/donation request
Projected attendance at event/project?
How many years has this taken place?
Attendance last time?
What percent of the funds raised will directly benefit people in southwest Wisconsin? Also what percent is used for administrative expenses?
Response Deadline
Date Format: MM slash DD slash YYYY
Sponsorship Details (if applicable)
Cost of Sponsorship
If available, what are sponsorship levels and associated benefits?
Level Cost Benefit
Describe the sponsor opportunity connected with your event/project?
Are there any other reasons this organization/program/event should receive funding?
Make donation or sponsorship check payable to:*
Address to send check:*
Street Address Address Line 2 City State ZIP Code
Event/Project Documents
Please upload any documents that will aid in our decision on your sponsorship request.
Acknowledgment*
Please review our sponsorship/donation policy above before submitting this form. After you click "Submit" you will receive an automatic email to the address you listed.
- I have read and I understand the guidelines, policies and approval process.
Email
This field is for validation purposes and should be left unchanged.

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Sponsorship / Donation Request Form

Organization Details

Event / Project Details

Sponsorship Details (if applicable)

Level	Cost	Benefit