Community Donation Request Form

Community Donation Request Form
Today's Date*

MonthDayYear
Date donation needed*

MonthDayYear
Name of Organization*
(This will be listed as the payee on the check if your request is approved)
County
Other County:
Contact Person*

First NameLast Name
Contact Phone Number*

Area CodePhone Number
Contact E-mail*
Organization's Address*

Street Address - (This is where the check will be mailed if your check is approved)

Street Address Line 2

CityState

Zip Code
Is this a tax exempt organization and/or activity?*

YesNo
Please describe your organization & mission.*
Type of donation needed:*

ServiceFinancialMaterialsOther
Dollar amount requested:*
(An amount is required, we cannot accept open-ended requests)
What will this donation be used for?*
Who will benefit from this donation?*
How will Confluence Health be recognized for this donation?*
What other funding sources are you seeking?*
Is this request from a Confluence Health employee or is an employee affiliated with the requesting organization?*

YesNo
If Yes, name of employee:
Did Confluence Health or Wenatchee Valley Medical Group contribute to your organization last year?*

YesNo
If Yes, who contributed?

Confluence HealthWenatchee Valley Medical GroupNot Positive
If Yes, what were the funds specifically used for?
If you have any additional information that would be helpful for the committee (such as flyers or brochures), please upload them here.

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