Northeast Wisconsin RTAC Funding Request Form

Northeast Wisconsin RTAC Funding Request Form
Northeast Wisconsin RTAC Funding Request Form NEW RTAC is an organized group of healthcare entities and other concerned individuals who have an interest in organizing and improving trauma care within Northeast Wisconsin. It serves as the unifying foundation to bring together all local, county, regional, state, federal and other agencies for the planning, education, training and prevention efforts needed to assure the exemplary care required for pre, acute and post injury trauma patients. The primary purpose of an RTAC is to design, implement and evaluate a trauma system within a region that is data-based, confidential and sensitive to the needs, resources, and limitations of each regional area.
The Northeast Wisconsin RTAC allocates limited funds to help organizations and services fulfill their goals. Our philosophy is centered on supporting requests that benefit the community as a whole. RTAC funds are not guaranteed and are on an “as available” basis. All requests will be pending Executive Council approval.
Date completed:*

MonthDayYear
Date
Organization for Consideration:*
Signature of Organization/Service Director/Designee:*
Name of Applicant:*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Make check payable to:*
Project description:*
Amounted Requested: (Please include breakdown of costs)*
How does this request relate to the mission of the NEW RTAC? *Performance Improvement *Injury Prevention *Education *Equipment*
*Performance Improvement *Injury Prevention *Education *Equipment
Version 01/20
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