Community Support Request Form

For Sponsorships, Partnerships, Memberships, or Other Support.

Date

To:

The - Name/Title

Full Name

District Hospital Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1. Organization / Community Group Details

Name of Organization

Type of Organization

Registration Number (if applicable)

Address

Contact Person

Position/Role

Phone*

Example: (123) 123-1234

Email*

Website/Social Media

2. Type of Request (check all that apply)

3. Purpose of the Request

Briefly describe the initiative, event, or project for which support is requested:

4. Event / Project Details

Title of Project/Event

Date(s)

Location

Target Audience / Beneficiaries

Expected Number of Participants / Beneficiaries

Goals and Expected Outcomes

5. Support Requested from the Hospital

Please specify what you are requesting (e.g., financial contribution, medical expertise, venue use, supplies):

6. Benefits to the Hospital

Explain how the hospital will benefit from supporting this initiative (e.g., publicity, community goodwill, health impact)

7. Additional Information

Please attach:

Authorized Signatory:

Name

Signature

Date