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

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

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.