Organization Name _________________________________________

Address __________________________________________________

Contact _________________________ Phone ___________________

e-mail ____________________________________________________

Activity or Event ___________________________________________

Mission of Organization ______________________________________

__________________________________________________________

__________________________________________________________

Statement of use (i.e., supplies, space, personnel, in-kind donation)

___________________________________________________________

___________________________________________________________


Requests will be considered based on resources available at the time of the request and whether the request meets the hospital’s goal of helping develop health and wellness, safety and community relationships.

Those excluded from consideration are groups with little impact on Logan County; political groups or candidates; religious groups or special interest groups espousing a religious or other message not in line with Logan Medical Center’s mission.


Return this form to:

Logan Medical Center
Public Relations & Mktg.
P. O. Box 1017
Guthrie, OK 73044

Or fax: 282-6790 – Attention: Cathie Cordis

For questions regarding your request, contact Cathie Cordis, 260-4170.