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Community Contribution Request
What regional area should your submission be directed to?
Des Moines, IA
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?
What percentage of your dollars stay local?
Please rank your organizational goals:
If you chose other, please specify:
Please specify the amount or describe the participation needed:
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?
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?
If other, please specify
In which area will this program help to improve the health of the community?
Patient Care Coordination
Mental Health Service Enhancement
Childhood Injury/Illness Prevention and/or Education
General Health and Fitness
If other, please specify
What are the benefits to the community if this request is approved?
Do you have specific outcome measures?
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?
Type of Donation
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?
Please select the appropriate item(s)
Health Education Information
All promotional material containing our logo(s) will need to be approved by Public Relations before printing.
Please select the appropriate item(s):
Print Ad Color:
Print Ad Size:
Is there anything else you would like us to know about your request?
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