Fillable APPLICATION FOR CHARITABLE CONTRIBUTION I. (Northside Hospital)

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APPLICATION FOR CHARITABLE CONTRIBUTION I. (Northside Hospital)

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Internal Use Only
D
ate approved: ___________
Amount approved: $_______
APPLICATION FOR CHARITABLE CONTRIBUTION
I.
ORGANIZATION CONTACT INFORMATION
Name of Organization:
__________________________________________________________
Address:
__________________________________________________________
City and Zip code:
__________________________________________________________
Name of Contact Person:
__________________________________________________________
Contact’s Phone Number:
__________________________________________________________
Contact’s Email Address:
__________________________________________________________
Is this organization a certified 501 (c) 3 corporation or other charitable organization under the U.S. Internal
Revenue Code? ______Yes. If yes, please attach documentation showing the most recent certification.
______ No
*Tax letters stating the value of goods or services in exchange for a gift must be s
ubmitted to
Sponsorships@northside.com
or mailed to the attention of Sponsorship at Northside Hospital, 1000 Johnson
Ferry Rd NE, Atlanta GA 30342 within 60 days post event.
II. E
XPLAIN THE PURPOSE OF THE ORGANIZATION
P
lease explain the organization’s purpose, and, if available, attach any relevant literature or other information
about the organization.
III.REQUESTED CONTRIBUTION
P
lease specify the amount of the requested contribution and/or specify the in-kind services requested.
Amount Requested:
In-Kind Services Requested:
$____________________
____ Equipment
____ Supplies
____ Other: ______________
____ Hospital Personnel
I
V. R
EASON FOR REQUEST
P
lease choose the activity or program category(ies) that best match your request:
____ Charity event for not-for-profit community organization
(Information regarding your event must be submitted along with this application)
____ Fund for a local community clinic
____ Emergency funds for individuals in the community
____Community building activity (e.g., physical improvements and housing, economic
development, community support, environmental improvements, coalition building, community
health improvement advocacy, workforce development)
____ Non-local community requesting help for response to natural disasters
____ Community health improvement services benefitting persons living in poverty
____ Subsidized health services
____ Other: _________________________________________________________________
Describe how the
donated funds will be used to address a community need and benefit the health of the
community, and attach any additional information describing the activity or program that is the subject of this
request. Additionally, if applicable, explain how the intended use aligns with one or more of Northside’s
top seven (7) community needs identified on Appendix 1 to this Application.
Explain how this request aligns with Northside’s mission set forth on Appendix 1 to this Application.
V. A
TTESTATION AND STATEMENT OF UNDERSTANDING
I ________________________ attest that the information in this application and its attachments is true and
accurate and that this request is not made for the purpose of influencing any governmental or legislative
decision or for any unlawful purpose. Additionally, on behalf of ____________________, I understand that
any funds awarded to the organization must be used to directly fund/support the activity stated in Section IV
above.
By:
________________________________ Date: ________________________________
APPENDIX 1
NORTHSIDE’S IDENTIFIED COMMUNITY NEEDS
Northside has identified the following as the top seven (7) community
needs:
Fiscal Years 2019 – 2021
Cancer
Cardiovascular Disease
Healthy Lifestyle Behaviors
Maternal and Infant Health
Diabetes & Obesity
Affordability, Access to Care & Insurance Coverage Status
Mental Health & Addiction
NORTHSIDE’S MISSION
Northside Hospital is committed to the health and wellness of our community. As such, we dedicate ourselves
to being a center of excellence in providing high-quality health care. We pledge compassionate support,
personal guidance and uncompromising standards to our patients in their journeys toward health of body and
mind. To ensure innovative and unsurpassed care for our patients, we are dedicated to maintaining our
position as regional leaders in select medical specialties. And to enhance the wellness of our community, we
commit ourselves to providing a diverse array of educational and outreach programs.
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APPLICATION FOR CHARITABLE CONTRIBUTION I. (Northside Hospital)

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Completed 6 June 2021

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