Sponsorship Request Form Sponsorship Request Form Name of Agency/Event: Mailing Address: Name of Person Making Request: Requestor's Phone #: Organization Phone #: Email Address: Is this a not-for-profit organization? Yes No Please upload any (PDF) documents proving your non-profit status and/or any documents related to your sponsorship request. Has Penn Highlands Healthcare ever sponsored your organization or this event in the past? Yes No If answered yes, for how much and when was the sponsorship? From which hospital(s) are you requesting a sponsorship? (Check all that apply) Penn Highlands Brookvile Penn Highlands DuBois Penn Highlands Clearfield Penn Highlands Elk Please write a brief description of the event or program you are requesting funds for or attach a letter describing the event and request: Please describe how this event (or program) will impact the health and/or well being of the citizens of our area: How much money are you requesting? Will Penn Highlands Healthcare receive promotional opportunities through this sponsorship? Yes No Please Describe: