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Sponsorship request

*Please select Novant Health Facility from which you are requesting support:
*Name of Requesting Organization:
*Tax ID Number:
*Contact First Name:
*Contact Last Name:
*Contact Phone:

*Contact Email:
*Organization Street Address:
Organization Website:
*Board Members:
Event/Activity Name:

*Event/Activity Date (must be a minimum of 12 weeks from date of submission):
*Location of Event:
Start Time:
End Time:  
*Type of event:

Is this a first year event?
Number of years event has been in operation:
*Expected Attendance (number of attendees/participants):
*Sponsorship amount requested:
*Percent of funds that directly impact organizations charitable purpose:
Publicity/benefits to Novant Health from sponsorship:
Deadline for ad/logo:
*Format for ad/logo:
* Description and history of event to be sponsored (how funds will be used):
How will this event impact the healthcare of our community?
Who is the target audience for this event?
What is the goal of this event/activity?
Will the results be measured, and if so, how?
*Describe how this event positively impacts Novant Health and your organization:
*Is there any exclusivity within the sponsorship levels? If so, please explain:
*List any other healthcare sponsors already committed:
Additional information we should consider in evaluating this request: