Request for Special Funding Application

Name of Organization:*
Date*
MM slash DD slash YYYY
Applicant Name/Title*
First Last
If awarded funds, when will these funds be disbursed for implementation of program/service?*
MM slash DD slash YYYY
Mailing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is your organization governed by a board that receives taxpayer support? (Hospital District, City Council, etc.)*
- Yes
- No
Yes, we are governed by:*
Description of Program/Item for which funding is requested:*
Cost per unit (if applicable)
Number requested (if applicable)
Total Amount Requested:*
Description of how this funding promotes health in our district. Include one measurable objective and expected outcome:*

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