Organization Name
*
Title
*
Contact Name
*
First Name
Last Name
Email
*
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Back
Next
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
Browse Files
Drag and drop files here
Choose a file
Files must be no larger than 1.6MB
Cancel
of
Back
Next
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
of
Back
Next
Submit Sponsorship Request
SUBMIT
Should be Empty: