Events and Sponsorship Request Form

If you would like the Community Health Education Center (CHEC) and Salem Health to consider a request for sponsorship, support for a community event, or other assistance, please submit your request by using the request form below.

Before submitting this request, please review the guidelines.

Click the Send Message button at the bottom of the screen when finished.

Date of request:

 

Requestor's information

Name:
Phone:
E-mail address:
Mailing address:
Best time and method to contact you:

 

Request's Type (check all that apply)

	Financial sponsorship and/or donation of materials
	Participation in a community event by hospital employees, physicians or volunteers
	Speaker for a community group or event
	Other:

 

Details of request

Name of group or organization making the request:
Name of event:
Date of event
Location of event:
What is the purpose/goal of this event or request:
Brief description of event:
Type of support or involvement requested:
If an event, who will be attending (target audience):
If an event, number of participants expected:
Are there special issues such as language, culture, or literacy that we should be aware of?
No Yes - If yes, please explain:
Other organizations who are expected to participate:
How will this event or sponsorship be publicized or promoted and by whom:
Are promotional opportunities available for Salem Health ? (i.e., ads in program, informational booth, etc.):
No Yes
If yes, please list promotional opportunities:
If requesting a speaker, is there a stipend or honorarium, and if so, how much:
Additional Details:
Describe how this request meets the priorities outlined in the guidelines:

 

For sponsorships or donation of materials:

Is your organization not-for-profit	No Yes
Amount of financial sponsorship requested:
Date financial support needed by:
Description of materials requested:
Date materials needed by:

 

Comments

Please let us know any other comments that may be helpful in the review of your request:
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