Community Sponsorship Request Form

Request Form

Community Benefit Request

Are you looking to request funding for a measurable outcome-based program or initiative that is implemented over a one-year period? If yes, select this request form.

NOTE: In order to qualify for funding, the organization must be tax exempt under section 501c3 of the IRS code and the program must support one or more health priorities and target populations as outlined in the request form.

Community Benefit Program awards typically do not to exceed $5,000.

Corporate Sponsorship Request

Are you looking to request funding support for a one-time event or activity that supports positive brand awareness and good corporate citizenship for Health New England? If yes, select this request form.

NOTE: In order to qualify for funding, the organization must be tax exempt under section 501c3 of the IRS code.

Corporate Sponsorships are typically limited to $2,500 and below.

Please complete all questions and be sure to scroll to the bottom of the form to submit it to us. Once you click “Submit” you will not be able to edit your form.
Name of Organization (Must be nonprofit, tax exempt under Section 5013c3 of IRS code)
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Organization Tax ID Number
Organization W-9 Form

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Point of Contact Information
Name

First NameLast Name
Title
Email
example@example.com
Phone Number

Area CodePhone Number
Are you currently a Health New England employer group?

YesNo
Corporate Sponsorship Information
Community Benefit Program or Initiative:
Program or Initiative Name:
Start Date / End Date
Time

:HourMinutesAM/PM Option
Event Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dollar Amount Requested
Has your organization ever received funding from Health New England before?

YesNo
If Yes, what was the amount received?
Description of Program or Initiative

0/150
Website with additional information available
Marketing Opportunities (Check all that apply. Skip question if n/a)

Program AdVideo ComponentCompany LogoSpeaking OpportunityPromotional GiveawaysExhibitor Table/BoothWebsite PublicityOther
Are there other sponsors for this program or initiative? If so, please list:

0/250
Provide a brief description of how your program or initiative supports Health New England’s mission.

0/500
Describe the age groups of your target population. Select all that apply:

Infant 0-1Children 2-12Teen 13-17Young Adults 18-24Adults 25-64Seniors 65 +
Is your target populate at risk/vulnerable? Select all that apply:

HomelessImmigrantLGBTQLow incomePersons with disabilitiesRefugeeUnemployedVeteranN/A
Describe the ethnicity of your target population. Select all that apply:

African-American/BlackAmerican Indian/Alaska NativeAsian-American/Pacific IslanderCaucasianHispanic/LatinoOther Racial or Ethnic MinorityN/A
Describe the gender of your target population. Select all that apply:

FemaleMaleGender Diverse
Select the following Health New England health priorities and other health factors that the program or initiative will improve (Check all that apply).

Food security / access to healthy food optionsPhysical activity programsBehavioral health/ mental healthSubstance use disorderInfant, child and family preventive healthInfant, child and maternal healthPre-school educationSchool-aged childhood educationEarly childhood literacyHigher education (high school/college) for at-risk youthResources to meet basic needsInstitutional racismChronic health conditionsHousing conditions
Describe how the program or initiative will impact the health outcomes of the target population or community.

0/750
Describe how you will evaluate the success of the program or initiative. Include a description of what success will look like.

0/1000
Describe your program goals, both short-term and long-term, and outcome measurements that will be used to evaluate the success of the program. Please include the name of the staff position responsible for collecting and reporting metrics.

0/1000
Please upload a copy of your program measurement collection form.

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Describe how your organization will recognize Health New England for its investment in your program.

0/500
Does your organization have a current relationship with Health New England? If so, please describe the relationship and include names of associates with whom you have worked.

0/250
How many people do you anticipate involving in this program or initiative?
Does the program or initiative support residents living in any of the following counties? Select all that apply:

HampdenHampshireFranklinBerkshireWorcesterMassachusetts Statewide
Additional Supporting Documentation

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