HHC Central Region Sponsorships and Grants Request Form

Organization Name*

Organization Overview*

Please provide background on your organization.

Organization Website

If applicable

Contact's Name*

Contact Phone Number*

Fax Number

Email Address*

Address of Organization*

Health Initiatives*

What health initiatives does your application most apply to?

Select

Please elaborate on your selection of "other."*

Service Area*

What service area/town does this apply to?

Select

Type of Support*

Select

Name of Sponsorship *

Name of the Program*

Ex. Diabetes Prevention Program

Program Support - Timeline Confirmation*

Are you submitting this request 120 days before needing the funds?

Select

Program Support - When do you need the support by?*

Program Support - Amount Requested*

Amounts for Program Support range from $1,000-$5,000. Please enter the requested amount below.

Sponsorship - Date of Event*

Sponsorship - Time of the Event *

Sponsorship - Event Location*

Sponsorship - Event Details*

Sponsorship - Dollar Amount of Requested Support*

Sponsorships range from $250-1000. Please do not request for a $ amount out of this range.

Sponsorship - Past Sponsorship by MMC*

Were you a past recipient of a sponsorship from Midstate Medical Center (MMC)?

Select

Name of Grant*

Grant - Details*

What is the grant supporting?

Grant - $ Amount Requested*

Grants awarded range between $2,500-10,000

Grant - Date $ Needed*

Reminder: Grant applications take 2-3 months to review. Please submit accordingly.

Impact Report Acknowledgement*

I acknowledge that by submitting an application for support that I need to submit an impact report by the end of HHC's fiscal year, September 30th. Please type your name below to confirm you acknowledge this ask of our Community Relations team. This only applies for Grant Requests and Program Support, not Sponsorships.

Please Upload your W-9, sponsorship flyer, or any applicable documents to your request.*

The W-9 is required. Upload all relevant documents (i.e. flyers, brochure, letter of explanation, etc.).

Drag and drop files here or

Date Submitted*

Please insert submission date.

Send me a copy of my responses

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