Strengthening the health and well-being of our communities is central to Mercyhealth’s mission of providing exceptional health care services, with a passion for making lives better. An integral way we do this is by partnering community health needs assessments. Together, we make lives better for those who live, work and play in our communities.

*ALL FIELDS MUST BE COMPLETED OR FORM WILL NOT SUBMIT

Welcome…Sponsorship Program
Organization Local Leader Name:
Your name:
DONATION RECIPIENT/ORGANIZATION:
County serviced: McHenry    Rock    Walworth    Rockford Region
Event/activity:
Date of event/activity: From: To: (mm/dd/yyyy)
Event Location & City:
What is the purpose/importance of this event to the organization?
How will the events contribute to the health and wellness of participates and /or the community?
What is your anticipated attendance for this event?
What was your attendance last year?
Are you a Mercyhealth Partner?: Yes   No
Email address:
Phone number: ( ) -
Address:
City/State/ZIP:
Mission or purpose of organization:
IRS Designation
(501(c)(3), 501(c)(4), Federal ID#, etc)
When do you need a decision? Date:(mm/dd/yyyy) (Please note: our system takes four weeks to process requests)
Overall, what is your fundraising goal? $
Amount Requesting from Mercyhealth? $
What % of your dollars stays local? $
Has Mercyhealth donated in the past? Yes   No
When?(mm/dd/yyyy)
For what:
Amount: $
How will Mercyhealth be recognized for its donation?
Does your organization plan to make additional requests within the next six months? Yes (If yes, for what event/activity )
No
Attach Sponsorship Levels and any other pertinent information:

(A copy will be sent to the email address entered above.)