Sponsorship Request

Organization Name:

Street Address:

City:

State: *

Zip Code:

Phone Number:

Fax Number:

Contact Person:

Contact Person's Title:

Contact Email Address:

If your request is for an event please complete the following event fields:

Event Name:

Event Date(s):

Event Time(s):

Event Location:

Event Audience/Expected Attendance:

Event Description:

For all requests, please complete the following fields:

Does this event align with the following health needs as determined by the CHNA?

Mental/Behavioral Health

Substance Abuse

Access to Care for Uninsured and Low-Income Persons

Other, please explain below

Please explain how your request aligns to the health need selected above:

Amount requested: $

Have you contacted anyone else from Mosaic Life Care concerning your request?

Yes

No

If yes, who have you contacted?

Has Mosaic Life Care sponsored your organization before?

Yes

No

If yes, how many years?

Word verification An error has occurred while getting captcha image