MedicaidEventForm

Event Participation Request Form

This form is used to request that Molina Healthcare of South Carolina participate in your upcoming event.

Is your event in South Carolina Yes No

* Denotes Required Fields.

*Contact Name :

*Email :

*Phone Number :

*Organization’s name :

Website :

Referred by:

*Describe the organization’s mission:

*List the counties the organization serves:

*Event name:

*Venue name:

*Venue street address:

*City:

*County:

*State:

*Zip Code:

*Event start date/time:

You must specify a value for this required field.

*Event end date/time:

You must specify a value for this required field.

*Expected total participants/attendees:

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

*Describe the event/project:

*List out all sponsors, including potential sponsors, for this event:

*Describe any logo or marketing requirements and deadlines:

Note any special needs or requests not mentioned above:

Volunteer Opportunities

Through Molina Healthcare’s employee volunteer program, Molina employees are encouraged to give back to the community. Molina offers employees paid-time off to do direct volunteer work with local organizations such as homeless shelters, after-school programs and food pantries. You can request volunteers for this event or any future events. Please let us know if you need Molina volunteers for this event:

Submitted Successfully

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.

By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. I understand and agree that my information will be used and shared in accordance with Molina Healthcare's Privacy Policy and Terms of Use.

You may have to pay for services that are not covered. You may also have to pay for services from providers not part of our network. If the services were an emergency, you don’t have to pay. If you need help, call Member Services.

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Event Participation Request Form

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