Community Support Request

Thank you for contacting Passavant Area Hospital. Passavant demonstrates its support for health, wellness and fitness through sponsorship of local not-for profit events and programming. Passavant Area Hospital (PAH) receives numerous requests from community organizations for donations, sponsorships and participation in special events. As a nonprofit organization, PAH 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 6 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, you can find information regarding a W-9 form 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 communitysupportrequest@passavanthospital.com. Forms are also available in the Marketing and Communications Office. For more information, call 217-245-9541, ext. 3129.






Contact Information

Name of Organization:
Contact Person:
Contact Phone (Work):
Contact Phone (Mobile):
Contact Email Address:
Organization Address:
City:
State:
Zip Code:

Organizational Information

1. Is your organization a 501 (c)(3) non profit or other tax-exempt organization?
 Yes No

2. Organization’s Website Address (if applicable)

3. What is your organization’s mission?

4. What cities or counties are served by your organization?

Request Information

Event/Program Name

Date

Location

Date Sponsorship Funds Needed

What type of support is requested? Check all that apply.
 Sponsorship Exhibitor Monetary Donation Giveaways Health Presentation Health Screening

What level of sponsorship are you requesting? Please include dollar amount.

Community Support Information

1. 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.

2. Does your initiative specifically address or support one of Passavant’s identified community health needs? (obesity, access to healthcare, and mental health)
 Yes No

If you marked “Yes” to the previous question, how?

Passavant Area Hospital Information

1. Is anyone at Passavant on your organization’s board or involved with this initiative?
 Yes No

2. Will Passavant receive any publicity or recognition for this donation?
 Yes No

If “Yes,” please elaborate.

3. Has Passavant provided support for your organization in the past?
 Yes No

If “Yes,” please elaborate.

4. 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?
 Yes No

Colorectal Cancer Screening Kit Pick Up

Posted on: March 13, 2017

Passavant Area Hospital and the Mia Ware Foundation are again partnering to bring prevention and awareness for colorectal cancer with a screening kit pick up and Community Health Talk later this month. The free kits will be available Thursday, March 30, from 4 to 6 p.m. and Friday, March 31, from 9 to 11 a.m. in the circle drive at the main entrance to Passavant, 1600 W. Walnut. Individuals should simply drive up, fill out a short questionnaire, talk to a nurse, and then complete the kit at home. The kit is then mailed to Passavant, with test results returned by mail in three to four weeks. The screening kits are new this year and are more convenient with only one stool sample required. They use the fecal immunochemical test screening method for hemoglobin in the stool. The test is considered the new standard for early detection of blood in the stool, one of the early warning signs of colorectal cancer. Colorectal cancer is the second leading cause of cancer deaths in the U.S., but if detected early, 90 percent of those deaths are preventable. [caption id="attachment_14043" align="alignleft" width="150"] Jan Rakinic, MD[/caption] In addition to the free screening kits, Passavant is presenting a Community Health Talk on Friday, March 31, with Jan Rakinic, MD, Professor of Surgery, SIU School of Medicine; Chief, Section of Colorectal Surgery. Dr. Rakinic topic is “Screening for Colorectal Cancer: Is it Worth the Bother?” The program begins at 12 noon in Meeting Rooms 2 and 3 at Passavant. A complimentary lunch is included. Call 479-5800 to register.

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