Donation and Sponsorship Request

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Name of Organization *

Mailing Address *

City, State, Zip *

Contact Person (First & Last Name) *

Phone Number *

Email *

Event/Project Description *

(Include date/time, location, admission cost, number of people served)

How will our assistance be utilized? *

Type of Request *

Cash

In-kind

Event held on the WHMS campus

Sponsorship

Door prize

Employees to volunteer at our event

WHMS promotional items

WHMS sponsored team (75% of team members must be WHMS employees)

Other

Type of Request Other

Describe Your Type of Request *

(amount, service, activity, in-kind item)

Has West Holt Medical Services participated in this event previously? *

Yes

If WHMS has participated previously, please explain how *

Are WHMS employees involved in this event? If yes, please list their names here *

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Hospital (402) 925-2811
Specialty Clinic (402) 925-2811
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406 West Neely Street, Atkinson, NE 68713
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Primary Care Clinic (402) 925-2811
405 West Pearl Street, Atkinson, NE 68713
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Retail Pharmacy (402) 925-2651
313 West Pearl Street, Atkinson, NE 68713

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Notice of Nondiscrimination

West Holt Medical Services includes West Holt Memorial Hospital, primary care clinic, all specialty clinics, West Holt Pharmacy, and other facilities providing services which are part of the WHMS system.

West Holt Memorial Hospital

This institution is an equal opportunity provider and employer.

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Donation and Sponsorship Request