Sponsorship Request Form

Please fill out this form to request sponsorship for your event or program. We will be in touch with you after we have an opportunity to review your request.

If you need to refresh your memory, reread the eligibility criteria.

Choose which region the event or program is in *

Organization Name *

Contact First Name *

Contact Last Name *

Contact Email Address *

Organization Website

Organization Street Address *

City *

State *

Zip Code *

Event or Program Name *

Event Date *

Must be at least 12 weeks from date of submission. If multiple dates, please use the first event in the series.

List all sponsorship opportunities

Amount Requested

Have you previously received funding from OrthoVirginia? *

Yes

Is this a first-year event?

Yes

Please provide a brief description of your event or program *

Location of event *

Who is your target audience for this event?

How many attendees do you expect at this event? *

Please list all sponsorship benefits and expected outcomes from this event *

Please list any other sponsors committed to date *

Medical Coverage Information

If requesting medical coverage, please list your personnel needs, time commitment, and/or any supply needs

I have read and understand the eligibility requirements *