MedicaidDonationForm

In-Kind Donation Form

This form is used to request that Molina Healthcare of South Carolina sponsor your:

* Denotes Required Fields.

*Contact Name:

*Email:

*Phone Number:

*Organization’s name:

Website:

*Describe the organization’s mission:

*List the counties the organization serves:

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

*Describe the organization’s donation needs (please include the date needed by and quantities, if applicable):

*Describe what the in-kind donations will be used for. Please be specific:

*Describe any logo or marketing requirements and deadlines:

*Note any special needs or requests not mentioned above:

Volunteer Opportunities

Through Helping Hands, Molina Healthcare’s employee volunteer program, Molina employees are encouraged to give back to the community. Helping Hands offers employees paid-time off to do direct volunteer work with local organizations such as homeless shelters, after-school programs and food pantries. Please describe any potential volunteer opportunities with your organization:

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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.

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In-Kind Donation Form

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