Sponsorship Request

Fields marked with an * are required

Organization Name: *

Organization Address: *

Is this a 501(C)(3) Non-Profit Agency? *

Do you have a W-9? (A W-9 will be required, if approved.) *

Contact Name *

Contact Email *

Sponsorship/Donation Amount Requested:

Event Date (if applicable):

Please explain sponsorship / contribution request:

What other organizations have agreed to sponsor this project/event?

Please explain items included with sponsorship (i.e. tickets, ad in program booklet)

How does this sponsorship tie in with West Tennessee Healthcare’s mission: (Mission: To improve the health and well-being of the communities we serve while providing exceptional and compassionate care.)

Are there other sponsorship levels available? If so, please list...

or attach sponsorship packet.

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West Tennessee Healthcare Employees Only

WTH Department Requesting Sponsorship

WTH Employee Name

WTH Employee Email

Org

Department

NONDISCRIMINATION NOTICE STATEMENT
West Tennessee Healthcare (WTH) does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, national origin, age, religion, disability, Limited English Proficiency or sex, including discrimination based on gender identity, sexual orientation, sex stereotyping or pregnancy in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by WTH directly or through a contractor or any other entity with which WTH arranges to carry out its programs and activities.

For further information about this policy, contact Amy Garner (731) 541-9914.

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Sponsorship Request