MedicaidEventForm

Event Participation Request Form

This form is used to request that Molina Healthcare of South Carolina participate in your upcoming event.

Is your event in South Carolina Yes No

* Denotes Required Fields.

*Contact Name :

*Email :

*Phone Number :

*Organization’s name :

Website :

Referred by:

*Describe the organization’s mission:

*List the counties the organization serves:

*Event name:

*Venue name:

*Venue street address:

*City:

*County:

*State:

*Zip Code:

*Event start date/time:

12AM

You must specify a value for this required field.

*Event end date/time:

12AM

You must specify a value for this required field.

*Expected total participants/attendees:

*Describe the organization’s audience(s) and the population(s) it serves:

*Describe the event/project:

*List out all sponsors, including potential sponsors, for this event:

*Describe any logo or marketing requirements and deadlines:

Note any special needs or requests not mentioned above:

Volunteer Opportunities

Through Molina Healthcare’s employee volunteer program, Molina employees are encouraged to give back to the community. Molina offers employees paid-time off to do direct volunteer work with local organizations such as homeless shelters, after-school programs and food pantries. You can request volunteers for this event or any future events. Please let us know if you need Molina volunteers for this event:

Submitted Successfully

Please complete required questions and resubmit

Please enter your email address in name@email.com format.

Please enter a 10 digit telephone number

Please enter a valid Zip code

Please submit any additional documents to SCSponsorshipRequest@MolinaHealthcare.com. In approximately 4 weeks, you will receive a reply to your request.

By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. I understand and agree that my information will be used and shared in accordance with Molina Healthcare's Privacy Policy and Terms of Use.

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Event Participation Request Form

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