System Community Contribution Request Form

System Community Contribution Request Form
To ensure we evaluate and assess each request, we have a team that reviews requests from across the organization and communities we serve on a monthly basis. Please note that it can take up to 45-60 days to have your request reviewed.

Aspirus is a non-profit, 501(c)(3) organization and only contributes to other non-profit 501(c)(3) organizations. 501(c)(3) organizations are exempt from federal income tax. A W9 form must be provided along with your request.

Aspirus does not support the following types of requests for sponsorships/donations:
- For profit businesses
- Politically focused organizations
- Proposals seeking general support for operating expenses, including salaries
- Events outside of the communities Aspirus serves
- Fundraising for individuals with a medical condition
- Causes that compete with the fundraising efforts of the Aspirus Family of Foundations
- 3rd party fundraisers
ORGANIZATION
Name of Organization:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website:
Please enter URL (e.g. aspirus.org)
Facebook Page:
Please enter URL (e.g. facebook.com/aspirushealth/)
ORGANIZATION CONTACT
Contact Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Are you an employee of Aspirus Health?*

YesNo
ABOUT YOUR ORGANIZATION
Is your organization a 501(c)(3) or nonprofit organization? A 501(c)(3) organization is exempt from federal income tax.*

YesNo
You have indicated that your organization is not a 501(c)(3) and thereforeare unable to process your request. Aspirus is a non-profit, 501(c)(3) organization and only contributes to other non-profit 501(c)(3) organizations. Thank you!
Tax ID number*
Upload a copy of your W9*

Cancelof
What is the focus of your organization?*
Are any Aspirus employees active in your organization*

YesNo
If yes, who?*
Would this be the first time you’ve received funding from Aspirus?*

YesNo
REQUEST DETAILS
What is the request for? Please provide a description of the request. *
What is the name of the program/event?*
Date of program/event:

MonthDayYear
Date
Amount requested (dollars):*
(Please be aware, fund distribution may take up to 8 weeks after approved…)
Date funds requested by:*

MonthDayYear
Date
How does the request align with the mission and vision of Aspirus? *
How would the funds be used?
What is the number of people that will directly benefit from the event/program/campaign?
What Community Health Needs are these addressing?

Mental HealthAlcohol & Other Drug Use (AODA)Diversity, Inclusion and BelongingAccess to HealthcareChronic DiseaseOther
What Aspirus communities are being served by the event/program/campaign? Please list counties:
How will funds promote health and well-being in the service area?
Is your organization validated on the Aspirus FindHelp website?*

YesNo (An Aspirus representative may contact you with more information)
Would Aspirus be the only health care sponsor?*

YesNo
Sponsor benefits (For example, Aspirus logo will be displayed on web page or Aspirus will get an ad in a program).
Was your organization referred by an Aspirus employee to complete this form?*

YesNo
If yes, please list the employee name:
Please upload any supporting documents and information.

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Should be Empty:

System Community Contribution Request Form

ORGANIZATION

ORGANIZATION CONTACT

ABOUT YOUR ORGANIZATION

REQUEST DETAILS