Tri-City Sponsorship Form

Tri-City Medical Center has refocused its community engagement activities to support projects that make a meaningful contribution to community health in our primary service areas (Carlsbad, Oceanside, and Vista), with particular focus on priority services provided by TCMC and the top health needs outlined by the Hospital Association of San Diego and Imperial Counties (HASDIC) Community Health Needs Assessment (CHNA). If your organization would like to request sponsorship please complete the below form, including which health needs your program or event will address and describe the outcome metrics or impact this investment will have in our community.

Application

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Status

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Approve Amount

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Notes

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Please select which sponsorship you are applying for. If you have multiple sponsorship requests, please provide one application per request:

Organization Information

This evaluation of the ongoing outreach efforts of Tri-City Medical Center's (TCMC) COASTAL Commitment is critical to its overall mission. This form will help your organization report specific community engagement practices and outcomes resulting from your partnership with TCMC. This data will be used to highlight partnership successes, as well as encourage continuous improvement in our community engagement activities.

Please only report outreach efforts that were impacted by TCMC sponsorship funding and in-kind support.

EVALUATION: Please confirm the following information you provided is accurate

Organization/Agency Name

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City

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Nonprofit #

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Federal Tax ID #

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: No

Website

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Primary Contact Person Details

First Name

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Last Name

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Phone Office

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Phone Mobile

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Contact Method

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Secondary Contact Person Details

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Phone Mobile

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Contact Method

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Organization/Agency Name

City

State

Zip

Website

Primary Contact Details

First Name

Last Name

Position Title

Phone Office

Phone Mobile

Primary Email

Preferred Contact Method

Secondary Contact Details

First Name

Last Name

Position Title

Phone Office

Phone Mobile

Secondary Email

Preferred Contact Method

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Other

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Deliverables and Reports

With this program sponsorship, your organization agrees to provide a detailed recap of results achieved within 15 days from the close of the program/event. If the program extends into multiple years, your organization agrees to prepare and provide an Annual Report, in writing, which can be presented by the organization to the Tri-City Healthcare District’s Board of Directors and/or staff if requested. The report should include all information requested in the Program Information section above, plus any other details you would like considered.

Agreement

We value our partnership and strive for success. We would appreciate any feedback you can provide on your experience and any areas of growth you can recommend. Thank you.

Submit

Please Fill Correct Data

Cancel

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Organization Information

Application Id

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Approved Amount

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Organization/Agency Name

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City

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State

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Zip

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Nonprofit

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: No

Website

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Primary Contact Person Details

First Name

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Last Name

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Position Title

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Phone Office

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Phone Mobile

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Contact Method

: Office phone, Mobile phone, Email

Secondary Contact Person Details

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Last Name

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Position Title

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Phone Office

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Phone Mobile

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Contact Method

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Details

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Approved

Rejected

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No Dates found

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: Yes

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History

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Approve

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Organization Information

Primary Contact Person Details

Secondary Contact Person Details

Primary Contact Details

Secondary Contact Details

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Deliverables and Reports

Agreement

Notes

Organization Information

Primary Contact Person Details

Secondary Contact Person Details

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History

Thanks for your submission. We will review your information and get back to you shortly.

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