UnityPoint Health - Des Moines

Contribution Request Form 

OrganizationTax IDTitleContact NameAddressCity, State, ZipEmailPhoneWere you referred by anyone at UnityPoint Health - Des Moines to fill out this form? If yes, please indicate the person's name and their department?Name of Event or ProjectDateDescription of EventIs this an ongoing project or one-time event?How would you best describe your event?



OtherDoes this project address either of these health priorities?
In which area will this program help to improve the health of the people of Central Iowa?



OtherWhat are the benefits to the community if this request is approved?Do you have specific outcome measures? If yes, how will they be measured?Who is your target audience and number of people impacted by the program?How is the event promoted?How many people plan to attend?What are your levels of giving/sponsorship and forms of recognition at each level?If your request is not awarded this time, do you want it considered for the next period?
Monetary Donation RequestRequested Dollar AmountDate Contribution NeededDoes this contribution help leverage other assistance?Check Made Payable to:How will the money be used? (percentage to program, expenses, national organization, etc)Does the money raised stay local? If so, what percentage?In-Kind RequestPlease select appropriate item(s)



OtherArtwork RequestPlease select appropriate item(s)
Logo ColorLogo formatPrint Ad Color
Print Ad Size**All promotional material containing our logo(s) will need to be approved by Public Relations before printing.**Upload Files:Is there anything else you'd like us to know about your request?