Sponsor

Join HelpRx.org as a Corporate Sponsor

We invite businesses and organizations to be a part of a transformative mission: to bring accessible healthcare to uninsured, low-income individuals battling chronic illness. By joining as a sponsor, your company will make a direct impact on lives in need while honoring the compassionate legacy of Emma Goldman. Complete the form below to take the first step in changing lives with HelpRx.org.

Corporate Sponsor Application Form

Thank you for your interest in becoming a corporate sponsor. After submitting your application, a HelpRx.org representative will reach out to discuss partnership details and match you with patients who need your support. Together, we can change lives and create a legacy of health and hope.

Business Information

Company Name

Industry/Field

Company Address

City, State

Zip Code

Website

Company Size

Company Size

Primary Contact Person

Full Name

Job Title

Email Address

Phone Number

Sponsorship Information

Sponsorship Preferences

Preferred Patient Demographic

No Preference

Specific Location (please specify)

Specific Age Group (please specify)

Other (please specify)

Anticipated Sponsorship Budget (optional)

Are you interested in receiving regular updates on the impact of your sponsorship?

Yes No

Additional Information

Please provide a brief statement on why your company is interested in partnering with HelpRx.org and any specific goals or values that align with this initiative:

Statement

Terms and Agreement

By submitting this form, you acknowledge that your company intends to support HelpRx.org and understands that participation in this program requires a commitment to uphold our values of compassion and social responsibility.

I agree to the terms and conditions.

Sponsor

Join HelpRx.org as a Corporate Sponsor

Corporate Sponsor Application Form

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