Community Support Request Form

Organization Name*

Address*

City*

State*

Zip Code*

Website

Executive Director

Mission*

Description of Organization*

Geographic area served by organization*

Federal Tax ID

Requestor's name*

Requestor's email address*

Requestor's phone number (xxx.xxx.xxxx)*

Is the requestor an employee of John Muir Health?*

Yes

EVENT OR ACTIVITY SUPPORT

Description of event or activity*

Requested amount*

Funding levels*

How will the funds be used?*

Date of event or activity

Time (hh:mm):

Anticipated number of people in attendance or served

Location

Type of event or activity*

Is the event or activity health related?*

Yes

Target population the funds will benefit*

Geographic area the funds will benefit (select all that apply)*

West Contra Costa

East Contra Costa

Central Contra Costa

Tri-Valley

Northern Alameda

Select the John Muir Health funding focus area that this program or service aligns with (select all that apply) *

Structural Racism, including diversity, equity, inclusion and belonging

Access to Care, including primary and specialty care services

Behavioral Health, including mental health services

Housing and Homelessness

None of the above

Promotional and/or engagement opportunities (e.g. logo in advertising, speaker request, etc.) *

Other Information

Please attach copies of the following documents, if available (maximum file size for all attachments: 7MB)

Copy of tax exempt status determination letter from the Department of the Treasury Internal Revenue Service
A list of the organization's or entity's Directors, Officers, or individuals on its governing body and their affiliations, if any, to John Muir Health
Promotional benefits, sponsorship options, and fair market value of benefits received