Funding Request Form

*Please indicate which funding priorities your request falls under:

Health & Wellness Safety & Prevention Community Betterment Disaster Response & Recovery Sponsored Causes (Involvement from 3 or more CRH employees)

Sponsorship

*Event/Group Name:

*Purpose:

*Amount requested:

*Date of event:

*Attendance:

Item request

*Item(s) requested:

Quantity:

Date needed:

General donation

Amount requested:

What specifically will these funds be used for?

Recognition/Support/Collaboration:

*What recognition or publicity will Crossing Rivers Health receive from this donation/sponsorship?

*List any Crossing Rivers Health employees or Partners of Crossing Rivers Health who are associated with your organization or supporting your request:

*What organization(s) are you collaborating with for this project?

Organization and Contact Information

*Organization/Group Name:

Contact person(s):

*Address:

*City:

*State:

*Zip code:

*Phone:

*Email address:

*Mission/Purpose:

Website:

*Is your organization non-profit?

Yes No

If yes, what status do you hold?

501(c)3 501(c)(6) Other

*Number of WI residents served:

*Number of IA residents served:

*Others:

Please feel free to attach supporting documents.

Submit