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):
Cause/Event/Program:
Event Date:
Event Time:
Location of Event/Program:
Organization's Address:
Contact Person
Title:
Email Address
Phone
Please provide the following information:
Purpose and goals of the Event/Program:
Cause/Event/Program details:
Beneficiary of Cause/Organization:
Community impacts and outcomes-including number estimated to be reached by this 501c3:
Penn State Health or Penn State College of Medicine mission(s) supported (patient care, education, research and community outreach):
Services/Benefits Penn State Health or Penn State College of Medicine receives as a result of sponsorship:
Demographics impacted:
Penn State Health and Penn State College of Medicine strongly believes in its values of respect, integrity, teamwork and excellence. This includes a deep commitment to diversity, inclusion and equity and supporting underserved and historically marginalized members of our community. Our expectation is that organizations we support also align with our values. To determine how well your organizational values align with those of Penn State Health and Penn State College of Medicine, we ask that you respond to the following questions.
Have you established and communicated an anti-discrimination statement or policy for your organization? If YES, check Yes below and provide either your anti-discrimination statement or policy as an attachment. If NO, we cannot process your request until a statement or policy is provided
Yes
No
Attach a copy of the anti-discrimination statement or policy.
Does your organization exclude any groups protected by anti-discrimination laws, (such as race, color, national origin, religion, age, sex/gender, sexual orientation, gender identity, physical or mental disability) from the services provided by your organization?
Yes
No
If yes, provide details of the exclusion(s) in the comment box:
Has your organization (and/or related family of organizations) been subject to any complaints of unlawful discrimination in the last three years which have resulted in an adverse finding by either a governmental entity (such as the EEOC, etc.), or from a court or similar legal tribunal?
Yes
No
If yes, provide details of the outcome of the complaint(s) in the comment box:
Do you conduct anti-discrimination training, including sexual and racial harassment prevention, for the employees and volunteers of your organization?
Yes
No
Penn State Health or Penn State College of Medicine employees involved (if any):
Penn State Health
or Penn State College of Medicine
champion involved (if any):
Please add any accompanying documentation that should be considered with your request including: sponsorship materials/levels, brochure, packet, flyer, or other informational materials.
If you have questions about this form, please contact Community Relations at 717-531-1698 or
CommunityRelations@pennstatehealth.psu.edu
.
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Contact Information