Community Donation Request Form

Community Support Request Form
Today's Date

MonthDayYear
Date donation needed

MonthDayYear
Name of Organization
(This will be listed as the payee on the check if your request is approved)
County
Other County:
Are you submitting this request on behalf of the organization?
Contact Person

First NameLast Name
Contact Phone Number

Area CodePhone Number
Contact E-mail
Organization's Address

Street Address

Street Address Line 2

CityState

Zip Code
Is this a tax exempt organization and/or activity?
Please describe your organization & mission.
Type of donation needed:
Dollar amount requested:
(An amount is required, we cannot accept open-ended requests)
What will this donation be used for?
Who will benefit from this donation?
How will Confluence Health be recognized for this donation?
What other funding sources are you seeking?
If rewarded: Physical address for funds request to be sent to:

Street Address

Street Address Line 2

CityState

Zip Code
Is this request from a Confluence Health employee or is an employee affiliated with the requesting organization?
If Yes, name of employee:
Did Confluence Health or Wenatchee Valley Medical Group contribute to your organization last year?
If Yes, who contributed?
If Yes, what were the funds specifically used for?
If you have any additional information that would be helpful for the committee (such as flyers or brochures), please upload them here.

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Community Support Request Form