Donation/Sponsorship Request Form

Once form is submitted our board of marketing and donations will review within 7-10 days and reach out to main contact provided.

Name of organization or reason for donation/sponsorship?(Required)
Name(Required)
First Last
Email(Required)
Phone(Required)
Have you or anyone in your family been seen as an orthodontic patient in our office?(Required)
- Yes
- No
If so please list Names:
Are you a non-profit organization?(Required)
- Yes
- No
Will you be sharing our business information about our donation/sponsorship?(Required)
- Yes
- No
Will our logo or contact be placed on any materials?(Required)
- Yes
- No
If so please describe:
Have we donated/sponsored your organization within the last calendar year?(Required)
- Yes
- No
Does your organization impact a child/children?(Required)
- Yes
- No
Do you regularly have the resources to cover your budget?(Required)
- Yes
- No
Will the proceeds go towards a local organization?(Required)
- Yes
- No
Are proceeds shared with any other organizations/people?(Required)
- Yes
- No
If so, Please list who:
Do you have a deadline for your donation/sponsorship request?(Required)
- Yes
- No
If so please list date:
Month
Day
Year
Please list donation/sponsorship amounts and details:(Required)
Text Opt-In(Required)
- By checking this box, I agree to receive texts and phone calls from Rapid City Orthodontics at this mobile number.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

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Full Name*
Patient's Full Name*
Email*
Phone*
Patient DOB*
MM slash DD slash YYYY
Untitled*
Text Opt-In*
- By checking this box, I agree to receive texts and phone calls from Rapid City Orthodontics at this mobile number.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.