Sponsorship Application Form | Riverside Health System l Southeastern VA

Complete all fields and press the Submit Application button to send the application. The Marketing and Communications Department will review the request.

Sponsorship Application Instructions

All bold fields are required.

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? Yes No If yes, do any of the affiliates sit on your current Board? Yes No Are any other healthcare entities or providers also supporting this event? Yes No Provide other healthcare entities or providers names