Sponsorship Application Form | Riverside Health System l Southeastern VA

Sponsorship Application Instructions

ALL FIELDS REQUIRED. If all fields are not completed, the form will not submit properly. Press the Submit Application button at the bottom to send the form to the Marketing and Communications Department who will review the request.

Organization Information

I have reviewed the Sponsorship Application Instructions and agree to these guidelines Organization Name Street Address City State Zip Code Salutation Contact First Name Contact Last Name Contact Title Email Address Contact Phone Organization Website Is this organization a certified 501(c3) entity under the U.S. Internal Revenue Code?

Event Information

Event Name Event Date Event Location Amount/Support Level Requested In-kind Services Requested Purpose of the Event/Sponsorship Target Audience Anticipated Attendance Numbers/Event Impressions Has RHS supported this event in the past? Yes No RHS Response Deadline

Community Impact

What is the primary focus of your organization and what is your impact on the community? Please include your mission, vision, and values. Where will the proceeds of this Event/Sponsorship go? How does this Event/Sponsorship support Riverside's mission, vision, and values? Are there any Riverside employees, executives, or Board members involved with your organization? No Yes If yes, do any of the affiliates sit on your current Board? No Yes

Please provide Affiliate name(s)

Are any other healthcare entities or providers also supporting this event? No Yes Provide other healthcare entities or providers names

ALL FIELDS ABOVE ARE REQUIRED. If all fields are not completed, the form will not submit properly.