Select the appropriate HSHS hospital from the list:








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Have you spoken with an HSHS colleague about this request?:

Is the organization a 501C3 non-profit agency?:

(Must be at least two weeks from request date)
Will St. Francis Hospital receive any publicity or recognition for the donation?:

If yes, please use the link below to upload documentation listing specific publicity and/or recognition by sponsorship level.
Has St. Francis provided support in the past?:

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