Organization Name
*
Title
*
Contact Name
*
First Name
Last Name
Email
*
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
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State
Zip Code
Is your organization in good standing as a 501(c)(3) non-profit in Louisiana?
*
Yes
No
Select the parishes your organization provide services in:
*
Ascension
East Baton Rouge
East Feliciana
Iberville
Livingston
Pointe Coupee
St. Helena
St. James
West Baton Rouge
West Feliciana
Do you or your organization have a relationship with Baton Rouge General?
*
Yes
No
If Yes, please explain the relationship:
If you were referred by a Baton Rouge General employee or board member, please list here.
Is the sponsorship for an event or a program?
*
Event
Program
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Event Information
Event Name
*
Event Date
*
/
Month
/
Day
Year
Date
Event Location
*
Please describe your event's goals and objectives:
*
Number of Attendees Expected
*
Is this a title or presenting sponsorship opportunity?
*
Yes
No
Will Baton Rouge General be the exclusive healthcare sponsor?
*
Yes
No
Sponsorship Amount Requested
*
Sponsorship Benefits
*
Sponsorship Packet Upload
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Program Information
Program Name
*
Please describe your program's goals and objectives:
*
Sponsorship Amount Requested
*
Sponsorship Benefits
*
Sponsorship Packet Upload
Browse Files
Drag and drop files here
Choose a file
Files must be no larger than 1.6MB
Cancel
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Submit Sponsorship Request
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