Community Contribution Request

Organization

Tax ID

First Name

Last Name

Address

City

State

Zip

Phone Number

E-Mail

Organization Website

What regional area should your submission be directed to?

This will help ensure your questions are routed to the team best equipped to answer - select the region you received care in, or the region that is closest to you.

Is your organization a 501(c)3?

Yes'No

What percentage of your dollars stay local?

Please rank your organizational goals:

Program/Event Name

Start Date

End Date

If you chose other, please specify:

Please specify the amount or describe the participation needed:

Program/Event Description

Include anticipated health impact/outcome

How many years have you hosted this program/event?

Anticipated number of participants/attendees:

How will you promote this program/event?

How will this program/event contribute to the health and wellness of participants and/or community?

When is your preferred response deadline?

Were you referred by anyone at UnityPoint Health to complete this form?

YesNo

Please indicate who referred you

Please indicate their department

Is this an ongoing project or a one-time event?

How would you best describe your event?

Community/Civic ActivityEducation RelatedHealth OrganizationNon-Profit OrganizationYouth FocusedOther

If other, please specify

In which area will this program help to improve the health of the community?

Patient Care CoordinationMental Health Service EnhancementChildhood Injury/Illness Prevention and/or EducationGeneral Health and FitnessCommunity Improvement/BettermentOther

If other, please specify

What are the benefits to the community if this request is approved?

Do you have specific outcome measures?

YesNo

How will they be measured?

Who is your target audience and number of people impacted by the program?

What are your levels of giving/sponsorship and forms of recognition at each level?

If your request is not awarded at this time, do you want it considered for the next period?

YesNo

Donation Information

Type of Donation

FinancialIn-KindSponsorshipOther

Financial Requests

Requested Dollar Amount

Date Contribution Needed

Does this contribution help leverage other assistance?

Check made payable to?

How will the money be used?

(percentage to program, expense, national)

Does the money raised stay local? If so, what percentage?

In-Kind Requests

Please select the appropriate item(s)

Door prizePensBagsHealth Education InformationBannerOther

Other item(s):

Artwork Request

All promotional material containing our logo(s) will need to be approved by Public Relations before printing.

Please select the appropriate item(s):

LogoPrint Ad

Logo format:

JPGEPS

Logo Color:

Black/WhiteColor

Print Ad Color:

Black/WhiteColor

Print Ad Size:

Upload files:

Is there anything else you would like us to know about your request?

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