• 2026 Donor Appreciation Celebration Sponsorship Form

    Please complete the sponsor information, select sponsorship levels, provide payment or pledge details, and sign the authorization section. Event details: Thursday, October 15, 2026, 5:30 p.m. – 7:30 p.m., Cedar Point Country Club.

  • Sponsor Information

  • Format: (000) 000-0000.

  • Sponsorship Levels

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  • Payment and Pledge Information

  • Payment Method*

  • Please mail check to:

    Western Tidewater Free Clinic

    Attn: Jessica Rockwell

    2019 Meade Parkway

    Suffolk, VA 23434

  • Please click here to pay by credit card: Pay Now

  • Authorization and Acknowledgment

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: