Forward Health Foundation Grant Application
Organization Name
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If this is an Essentia Health - Itasca Lakes request, which department:
Date of Request
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Month
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Day
Year
Name of Contact Person
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First Name
Last Name
Phone Number of Contact Person
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Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email of Contact Person
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Dollar Amount Requested
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Please indicate from which fund you are requesting support:
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Please Select
General Community Grant Request
Jim Tarbell Cancer Care Fund
Cornerstone Employee Project Fund
Briefly explain the project or equipment for which you are requesting funds:
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What are your intended outcomes for this project/equipment?
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Approximately how many residents of the Deer River area will this project/equipment benefit?
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Which of the Foundation's focus areas will this request address:
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Prevention: Support efforts to prevent disease and promote healthy lifestyles.
Delivery of Local Health Care: Enhance and support programs, initiatives, and equipment for patient or resident care, and/or provide support to staff in their work.
Community Health and Well-being: Collaborate with area organizations who seek to improve health and quality of life for residents in the Deer River area.
Have you requested support from any other entities? If so, from where?
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Have you received promise of financial support from any other entity?
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Please upload any additional, supporting documentation, including equipment quotes (if applicable):
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