For organizations

Community Partner Request

For organizations seeking to collaborate, host events, or refer populations.

Organization

Organization name*Org typeWebsiteEIN (if applicable)Year foundedMailing addressCityStateZIPCounties served

Primary Contact

Full name*Title / rolePhone*Email*Preferred contact method

Partnership Interest

Areas of interest*

Refer clients to RAINCo-host education / outreachProvide clinic / event spaceFunding / grant collaborationWorkforce / training pipelineOther

Proposal — what do you have in mind?*Populations you primarily serve

Authorized Signature

Typed signature (authorized representative)*

RAIN by RMBI · Rural Access Integration NetworkConfidential — protected health information