Philanthropy Sponsorship Request Form

Optum Washington, The Everett Clinic, The Polyclinic

Optum Oregon, Oregon Medical Group

Please fill out this sponsorship request form. A member of our team will reach out to you for review, approval, and next steps. Thank you!

Requestor's Information

If you are filling this out on behalf of the organization, please fill out your information below.

Your Name

Your E-mail Address

Your Phone Number

Your Department

Today's Date

mm/dd/yyyy

Organization's Information

Name of Organization

Organization's Address

Include full street address, city, state, zip

Organization's Contact Name

Organization's Contact E-mail Address

Organization's Phone Number

Organization's Fax Number

Event Information

Name of Event

Date of Event

mm/dd/yyyy

Location of Event

Include full street address, city, state, zip

Anticipated Attendance

How many years has this event existed?

Purpose of Event

Fundraiser, community health, wellness event, etc.)

Type of Support Requested

Financial

Employee Involvement

Other (please explain in next field)

If you selected "Other" above, please explain:

Requested Sponsorship Amount

Deadline to Commit Support

mm/dd/yyyy

Does sponsorship allow for healthcare exclusivity?

Yes

Support Documents

Please attach the following documents with your request:

Drop your files here

Send me a copy of my responses