Baptist Health Deaconess - Community Health and Outreach

Organization Name:

Address:

Contact Person Name:

Email:

Phone:

Purpose/Mission of your Organization:

Which geographical area(s) does your organization serve?:

Is your organization tax exempt?:

YesNo

Your Tax ID Number:

What are you requesting?:

Give more details of your request:

For example: Event Name, date, location, dollars requested donation amount, ad specs/ad due date, etc.

List Baptist Health Deaconess employees involved with your organization and their role:

Board member, volunteer, etc.

Has Baptist Health Deaconess funded your organization or this event in the past?:

YesNo

Attach a copy of the organization's W-9 form:

If tax ID not available, attach copy of tax exempt status:

Attach any other relevant files:

Sponsorship Request