Community

Community Support Request

Thank you for contacting Passavant Area Hospital (PAH). Please use the form below to make your request.

Passavant demonstrates its support for health, wellness and fitness through sponsorship of local not-for profit events and programming. Passavant Area Hospital receives numerous requests from community organizations for donations, sponsorships and participation in special events. As a nonprofit organization, we must give careful consideration to whether and to what extent these requests support our hospital’s mission.

We also strive to address our identified community priorities of obesity, mental health, and access to care. Preference will be given to supporting community programs that are improving the health status and quality of life for underserved, low income or vulnerable members of our communities.

Nonprofit 501(c)(3) organizations, tax-exempt entities and other organizations may submit a request for support a minimum of six weeks in advance. Completion of this application does not guarantee funding of your request. Please be prepared to submit your organization’s IRS W-9 form where requested in the request form below. If you do not have a W-9 form, you can find information on the IRS website.

Organizations interested in support for programs consistent with this mission should submit their request using the form below. Questions can be referred to contactpassavant@mhsil.com . Forms are also available in the Marketing and Communications Office. For more information, call 217-245-9541, ext. 3129.

* denotes required fields.

We will contact you within two weeks of receiving your request. A confirmation email will be sent to the email address supplied.


Request Information

Name of Organization
Contact Person
Contact Phone (Work)
Contact Phone (Mobile)
Contact Email Address
Organization Address
City
State
Zip
Is your organization a 501 (c)(3) non profit or other tax-exempt organization?
Organization’s Website Address (if applicable)
What is your organization’s mission?
What cities or counties are served by your organization?
Event/Program Name
Date
Location
Date Sponsorship Funds Needed
What type of support is requested? Check all that apply.




What level of sponsorship are you requesting? Please include dollar amount.
Briefly describe how your request can improve the health of our community. Include your target audience, the number of people to be served, and how you will use this donation.
Does your initiative specifically address or support one of Passavant’s identified community health needs? (obesity, access to healthcare, and mental health)
If you marked “Yes” to the previous question, how?
Is anyone at Passavant on your organization’s board or involved with this initiative?
Will Passavant receive any publicity or recognition for this donation?
If “Yes,” please elaborate.
Has Passavant provided support for your organization in the past?
If “Yes,” please elaborate.
If a Passavant sponsorship/contribution is provided, the use of those dollars is to be restricted to the purpose as stated in this application. Do you accept this restriction of funding?