Charitable Giving - Request Form

Requests must be submitted at least 60 days before the needed date in order to be considered.
* All fields marked with an asterisk are required.

Requesting Organization Information
Organization *
Contact Name *
Address *
	City * State * AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip *
Phone *
Alternate Phone
Fax
Email *
Organization Web Address
Please briefly state your organization's mission *	Text limit: 250 characters   Text entered:
Is your organization a 501(c)(3) non-profit? * Yes No If Yes, please provide Federal Tax ID Number * Percentage of income from United Way % Percentage of income from State or Federal Grants %
Event/Program Information
Event/Program Title *
Event/Program Date(s) *	Start:              End:
Geographic area served * (City, County or Region)
Type of Donation Requested *	Financial - Amount requested: $ Health Promotion Items: Event Participation: Other:
Please briefly describe the event/program and participant demographics * Text limit: 500 characters   Text entered:
How will the event/program contribute to the health and wellness of participants and/or the community? * Text limit: 500 characters   Text entered:
How will Dean Health System be recognized for this donation? * Text limit: 500 characters   Text entered:
* I verify that the information provided above is correct and accurately represents the purpose and needs of the requesting organization.