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

Duck Race Winners

Posted on: June 5, 2017

Here are the winners from yesterday’s 23rd Annual Duck Race for Lifeline at Nichols Park in Jacksonville: 1st Place                Nancy Wood, $1,000 2nd Place               Morgan County Abstract Company-Amy Coats, $500 3rd Place               Angela Coffman, $300 4th Place               Bob Morris, $200 5th Place               Mr. and Mrs. Brian Glascock, $100 Passavant Gift Shop Gift Certificate 6th Place               Carrie Sheppard, $100 Passavant Gift Shop Gift Certificate 7th Place               Tena White, $100 Passavant Gift Shop Gift Certificate 8th Place               Brenda Coultas, $100 Passavant Gift Shop Gift Certificate 9th Place               Jacksonville Noon Rotary, $100 Passavant Gift Shop Gift Certificate 10th Place             Midwest Emergency Department Physicians, $100 Passavant Gift Shop Gift Certificate Passavant’s Lifeline Program provides 24-hour help and medical assistance. The event raised $37,555 for the Lifeline Program at Passavant in their mission to improve the health of the people and communities they serve. Bruce Selway holds the winning duck for everyone to see. His daughter, Katie, assisted him at the finish line.

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