Community Donation Application

If you wish to request consideration of a sponsorship or a grant from Presbyterian Healthcare Services, please complete this form and submit it to Julia Ruetten, jruetten@phs.org, as early as possible prior to the date funding is needed.

* = indicates required fields

Organization Information

Name of Organization*

Type of Organization*

Organization website*

Organization Purpose or Mission Statement*

Contact Information

Point of Contact*

Phone Number*

Email Address*

Program/Event Information

Program/Event Name*

Type of Program/Event*

Program/Event Date*

Expected Attendance or Community Reach*

Program/Event Description (include details on the intended use of the donation)*

Any Additional Information*

Sponsorship Level or Grant Amount Requested*

Will Presbyterian be acknowledged as a supporter?*

Yes

Attachments