Sponsorship Request

It is Good Samaritan's policy that all community support, be it monetary, supplies or services be evaluated to determine if the organization or event: 1) promotes wellness; 2) meets the mission of the hospital; 3) meets community health needs assessment goals; 4) is given in response to a national, regional or local disaster; or 5) supports community-wide endeavors that will improve the lives and livelihood of the communities served by Good Samaritan. The hospital's mission and its role as a corporate citizen will serve as a guide in the determination of sponsorship approval. The hospital defines wellness as any event, service or supply that promotes healthy lifestyles through education or physical activities or improves the health status of the communities served by the hospital. Click here to see our Sponsorship Score Sheet. This sheet is utilized to review requests. Requests must have a score of 11 or higher to be considered. Travel sports teams and individual player sponsorships will not be considered.

Our Sponsorship Committee meets on a monthly basis to review requests. All requests will receive a determination letter from the Good Samaritan Marketing Department within 10 business days of decision.

Is this organization located in one of these Indiana counties: Knox, Daviess, Gibson, Greene, Pike, Sullivan OR one of these Illinois counties: Crawford, Lawrence, Richland, Wabash?*

YesNo

Requester Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Organization Name*

Please upload all information regarding your sponsorship request. (Letter, sponsorship form, organization information). Information must be uploaded for consideration.*

Amount Requested*

Is this organization Not-for-Profit?*

YesNo

Does this request meet our sponsorship guidelines? (Check all that apply)*

Promotes wellnessMeets the mission of the hospital (Provide excellent health care by promoting wellness, education and healing through trusting relationships.)Meets Community Health Needs Assessment goals (Please see those here https://www.gshvin.org/about-us/2022-community-health-needs-assessment/)Response to a national, regional or local disasterSupports community-wide endeavors that will improve the lives and livelihood of the communities served by Good Samaritan.

What is the date you must have a response by?

Date

Address for Sponsorship Payment*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Since your organization is not located within our service area, your sponsorship request will not be reviewed, therefore the submission form has been disabled.

If you think this is an error, please feel free to mail your request to:

Good Samaritan Marketing
520 S. Seventh Street
Vincennes, IN 47591

Thank you.