Completion of the information below serves as the electronic signature of the individual completing this application and attests to the accuracy of the information provided.
I, the Requester, understand that I am requesting grant funds from the North Central Region Healthcare Coalition and that such funds are restricted under the guidelines set forth by the Hospital Preparedness Program, the Governance of the North Central Region Healthcare Coalition, and Trailhead Institute (fiscal agent). I agree to provide any documentation required by the Governance Board and/or fiscal agent to authorize payment or review of appropriateness of the request.