1000 Hour Form for 2022-2024

Consent and Signatures
The information contained in this application, as well as testing results, will remain confidential. The only information that will be made available to the general public is the name of the entity receiving funds from Women for a Healthy Environment. I agree that the information herein are true and correct. I further agree that I have received approval from my administration to submit this request, with the expectation that it will provide, at a minimum, short-term remediation and create a plan for long-term resolution of lead and radon exposure, as deemed necessary by testing. I agree that if my childcare facility or school is awarded a grant, I will ensure that test results will be shared with my school or childcare center staff, parents, and community. *
Please sign your name
If there are any other questions, comments or concerns, please address them below.
If you have tested for lead and/or radon, please provide documentation of test results below. If you have received quotes for lead or radon testing/mitigation, please submit below.

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1,000 Hours a Year Initiative: Addressing Lead and Radon in Learning Environments