Requesting Organization Summary

Please provide an overview of the organization*


Tax Status*


Type of Contribution*


If Services, please describe:

Is this an Annual Event?*

Project Scope
Describe in detail the project or activity for which support is being requested, including goals, benefits of the program, length of time for the project to be completed, budget, other sources of income, etc.

Project Description

Please identify the individuals or groups served, the location (county) served and the anticipated number of individuals to be served.

Whom will the contribution/sponsorship benefit?*

MSHA is committed to "Bringing Loving Care to Health Care".  We exist to identify and respond to the health care needs of individuals and communities in our region and to assist them in attaining their highest possible level of health.

How does this request support the mission of Mountain States Health Alliance?*

It is important to MSHA that it reports accurate contribution numbers, so please list any goods or services and their monetary value that this request, if granted, generates.

List all goods or services MSHA will recieve from the project/event (i.e. dinner tickets, advertisements, etc) and their monetary value.*