Sponsorship Form

Round Rock Sertoma

If you, or someone you know, is in need of assistance for hearing problems, please complete the form below and click the "Submit" button which will automatically transfer your request to the Sponsorship Committee. Assistance is limited to people that live in the Round Rock Independent School District. Also, the submitter must be the parent, guardian, or recipient if for an individual. Requests for assistance may also involve the release of medical information to a designated Sertoma member which would require completion of a HIPPA Release Form. For an organization or charity, it needs to be an officer of the organization or a Sertoma member. A Sertoma member will contact you personally and provide an update to your request. If you would prefer to submit your request via U.S. Mail, click here for an Adobe PDF Sponsorship Request Form.

Sponsorship Request Form
Type Recipient:	(Choose One)
Recipient Name:
Recipient Address:
Recipient Telephone:
Recipient EMail:
Type Support:	(Choose One)
Amount:	(If Financial Support Request, Provide Rationale Below)
Submitted By:
Relationship to Recipient:	(Choose One)
Relationship to Sertoma:	(Choose One)
Submitter Address:
Submitter Telephone:
Submitter EMail:
Purpose of Request:	(Briefly describe the situation and specific request in detail, including an explanation for any requested financial assistance. Explain how the sponsorship by SERTOMA will positively affect the parties involved.)

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Last modified: 05/06/08