In addition to filling out the online submission below, in order to actually receive any donation or sponsorship that may be approved for your organization, you will need to print, complete and have ready to provide:

  • W9

West Valley Medical Center Donation Request Form

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Type of Organization

Has your organization submitted a request in the past 12 months?
Was your request approved?
General Internet communication is inherently not secure. DO NOT send data considered confidential or private in nature on this form. (e.g., Social Security Numbers, Diagnosis Information, Credit Card Numbers, etc.)