Community Sponsorship Request
Submission Requirement
Community sponsorship request applications must be submitted a minimum of 45 days prior to the date of the event or program.
Applications submitted less than 45 days prior to the event date are not guaranteed to be processed and/or paid (if approved) by the date of the event.
Submission Requirement Acknowledgement:
I acknowledge I have read and agree to the submission timeframe as noted above.
General Information
Submission Date:
Organization Requesting Sponsorship:
To whom should the check be written?
Submitter's Name:
Submitter's Email:
Internal Cost Center/Budget/Gift Fund Number (for internal applicants only):
Event Title:
Event Date:
Event Time:
Estimated Event Attendance:
Location of Event:
Organization's Address:
Organization's Contact Person
Title:
Email Address
Phone
Please provide the following information:
Has Penn State Health previously sponsored or supported this event?
Yes
No
List Pertinent Event Details:
Beneficiary of Cause (Select all that apply):
American Indian/Alaska Native
Asian/Pacific Islander
Black/African American
Children/Youth
Disabled
English Language Learners
Families
Hispanic/Latino
Immigrant/Refugee
LGBTQ+ Community
Low Income/Poor
Men
Migrant Workers
Military/Veterans
Schools/Education/Students
Seniors/Elderly
Single Parents
Unemployed
Unhoused
Uninsured/Underinsured
Women
Other
If 'Other' is selected, please provide the cause:
Penn State Health supports a variety of worthy causes and non-profit organizations that align with our four primary missions. Which of our four mission pillars does your request support? (Select all that apply.)
Education
Patient Care
Research
Community health
N/A
We place particular emphasis on causes and programs that support and enhance community health, as they directly impact on improving the health of residents within our service area. Through various methods of community engagement and dialogue with health experts, we have identified three top community health needs that we prioritize. Which of these priority health areas does your request support? (Select all that apply.)
Mental Well-Being
Food and Nutrition Security
Physical Well-being
N/A
Penn State Health’s service areas include six Pennsylvania counties that are home to 75% of our patient population. Which of these supported service areas does your request fall under? (Select all that apply.)
Berks
Cumberland
Dauphin
Lancaster
Lebanon
Perry
N/A
Provide any additional comments/information about your community impact.
Sponsorship Benefits:
Penn State Health or Penn State College of Medicine employees involved (if any):
Please Upload Sponsorship/Event Materials:
If you have questions about this form, please contact Community Relations at 717-531-1698 or
CommunityRelations@pennstatehealth.psu.edu
.
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information