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FY 2025.2026 Fallbrook Regional Health District Community Health Contract Grant Application
For Fiscal Year 2025-2026
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Language
English (US)
Spanish (Latin America)
1
Tax Exempt Status
*
This field is required.
1. The agency must be an incorporated nonprofit organization with a tax-exempt status under California state law and Section 501(c)(3) of the Internal Revenue Code, or, be a public/governmental agency, program or institution. Newly established agencies must: a. Demonstrate, through written agreement with a 501(c)(3) qualified agency that, for the one-year period of the CHC, they will fall under the auspices of that qualified agency. The agency providing the umbrella status must meet the District requirement of being an established provider of healthcare related preventive or intervention services to the public in the District community. b. Secure 501(c)(3) status within the CHC funded year. If they fail to secure 501(c)(3) status, they will be ineligible for subsequent application for Fallbrook Regional Health District funding until such time as proof of 501(c)(3) status has been attained and presented.
YES
NO - Contact District staff.
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2
Service Area
*
This field is required.
What area(s) will this program serve (check all that apply).
Bonsall
De Luz
Fallbrook
Rainbow
None of these areas - not eligible for consideration
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3
Will no less than 80% of the program recipients live within the communities of Fallbrook, Rainbow, Bonsall or De Luz?
*
This field is required.
YES
NO - not eligible for consideration
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4
Collaborative/Joint Application
*
This field is required.
Is this application being submitted in collaboration with another agency?
YES
NO
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5
Organization Information
*
This field is required.
Please provide the legal name of the organization, as it appears on your 990. If you have a different DBA or nickname please add that in the box adjacent to the legal name.
Legal Name
DBA (if Applicable)
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6
Contact Information
*
This field is required.
Please add the contact information for the person responsible for the submission and monitoring of this grant application.
Contact Name
Title
Primary Contact Phone
Email Address
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7
Organization Physical Address
*
This field is required.
This is the primary address where the Organization provides services.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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8
Board of Directors
*
This field is required.
Please upload a list of your Board of Directors: include Full Name - First, Last, Board Position, Professional Affiliation/Industry and contact email address. PDF format is preferred.
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9
Financial Documents - Audit
*
This field is required.
Most recent audited financials with management letter – if your agency does not have audited financials please include the year ending P&L and Balance Sheet for the last two years. *Please note that audited financials will be required for any agency older than 5 years or with an annual budget over $500,000. PDF format is preferred.
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10
Financial Documents - P&L and Balance Sheet
*
This field is required.
Most recent Fiscal year end P&L and Balance Sheet. PDF format is preferred.
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: 10.6MB
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11
Financial Documents - 990
*
This field is required.
Most recent 990. PDF format is preferred.
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12
Organization’s Mission Statement
*
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13
Organization’s Vision Statement
*
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14
Organization History & Accomplishments
*
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Briefly describe your organization’s history and notable accomplishments from within the last 5 years as it relates to the provision of this program.
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15
Program Name/Title
*
This field is required.
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16
Brief Program Description
*
This field is required.
Please provide a short description of the program. This is the "elevator speech version", you will have the opportunity to fully explain the program later.
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17
Is this a new initiative/service or established program within your organization?
*
This field is required.
New Initiative/Service
Established Program
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18
Did this program receive FRHD CHC - Grant funding last funding cycle (FY 24.25).
YES
NO
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19
Describe the impact of the program to date. Briefly explain how the service/intervention has worked - include cumulative metrics from the Q1 and Q2 Impact reports.
*
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Please limit your response to 250 words.
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20
If this program was previously funded, please provide an example of how the District's funding of this program was acknowledged.
Please provide a pdf or image of how the acknowledgement was presented.
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21
Funding Amount Being Requested
*
This field is required.
Please fill in the total amount of funding being requested from FRHD through this 2024.2025 CHC Grant cycle.
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22
Program Information - Type
*
This field is required.
Is this program time bound or ongoing?
Time Bound
Ongoing
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23
Time Bound Program Dates
Please select the start and end dates for this program.
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24
Projected number of residents that will directly benefit (participant/client) from this program.
*
This field is required.
The number of residents that receive the service or who are enrolled in your program.
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25
Target Population - Age
*
This field is required.
List the percentages of your program participants’ ages. Percentages must add up to 100%
Percent of program participants
Estimated number of participants
Children (infants to 12)
Row 0, Column 0
Row 0, Column 1
Young Adults (13-17)
Row 1, Column 0
Row 1, Column 1
Adults (18-60)
Row 2, Column 0
Row 2, Column 1
Seniors (60+)
Row 3, Column 0
Row 3, Column 1
We do not collect this data (indicate with 100%)*
Row 4, Column 0
Row 4, Column 1
Children (infants to 12)
Young Adults (13-17)
Adults (18-60)
Seniors (60+)
We do not collect this data (indicate with 100%)*
Percent of program participants
Row 0, Column 0
Estimated number of participants
Row 0, Column 1
Percent of program participants
Row 1, Column 0
Estimated number of participants
Row 1, Column 1
Percent of program participants
Row 2, Column 0
Estimated number of participants
Row 2, Column 1
Percent of program participants
Row 3, Column 0
Estimated number of participants
Row 3, Column 1
Percent of program participants
Row 4, Column 0
Estimated number of participants
Row 4, Column 1
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26
Target Population not collected - Age
*
This field is required.
If you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question does not apply to your organization
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27
Target Population - Gender
*
This field is required.
List the percentages of your program participants’ gender identification. Percentages must add up to 100%
Percent of program participants
Female
Row 0, Column 0
Male
Row 1, Column 0
Non-binary
Row 2, Column 0
Unknown*
Row 3, Column 0
Female
Male
Non-binary
Unknown*
Percent of program participants
Row 0, Column 0
Percent of program participants
Row 1, Column 0
Percent of program participants
Row 2, Column 0
Percent of program participants
Row 3, Column 0
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28
*Target Population - Gender
*
This field is required.
If you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question does not apply to your organization
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29
Target Population - Income Level
*
This field is required.
List the percentages of your program participants' income limit category - 2012 HUD – AMI Income limits (4 person family). Percentages must add up to 100%
Percent of program participants
Extremely Low-Income Limits, ceiling of $32,100
Row 0, Column 0
Very Low (50%) Income Limits, ceiling of $53,500
Row 1, Column 0
Low (80%) Income Limits, ceiling of $85,600
Row 2, Column 0
Higher Than Listed Limits
Row 3, Column 0
We do not collect this data (indicate with 100%)*
Row 4, Column 0
Extremely Low-Income Limits, ceiling of $32,100
Very Low (50%) Income Limits, ceiling of $53,500
Low (80%) Income Limits, ceiling of $85,600
Higher Than Listed Limits
We do not collect this data (indicate with 100%)*
Percent of program participants
Row 0, Column 0
Percent of program participants
Row 1, Column 0
Percent of program participants
Row 2, Column 0
Percent of program participants
Row 3, Column 0
Percent of program participants
Row 4, Column 0
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30
*Target Population - Income Level
*
This field is required.
If you indicated that you do not collect data on the above question, please provide a rationale as to why that information is not sought. Write NA if this question does not apply to your organization
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31
What language(s) can this program accommodate:
*
This field is required.
Where most or the at least half of the program can be provided in the participant's primary language.
English
Spanish
Tagalog
Chinese (Mandarin/Cantonese)
Other
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32
What demographic group does this program predominately serve:
*
This field is required.
Select the one category that best describes your program's participants
Youth - school based
Older Adults
Youth - other setting
Special Populations
Community - Health & Fitness
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33
Program/Services Description - Social Determinants of Health
*
This field is required.
Please select the following SDOH your program directly addresses. Select only those that your goals and objectives will demonstrate a measurable outcome. You will be asked to explain how the SDOH is addressed below.
Economic Stability (Employment, Food Insecurity, Housing Instability, Poverty)
Education Access & Quality (Early Childhood Education and Development, Enrollment in Higher Education, High School Graduation, Language and Literacy)
Social & Community Context (Civic Participation, Discrimination, Incarceration, Social Cohesion)
Healthcare Access & Quality (Access to Health Care, Access to Primary Care, Health Literacy)
Neighborhood & Built Environment (Access to Foods that Support Healthy Eating Patterns, Crime and Violence, Environmental Conditions, Quality of Housing)
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34
Social Determinants of Health - Economic Stability
*
This field is required.
Please describe how this program/service addresses the SDOH of
Economic Stability.
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35
Social Determinants of Health - Education Access and Quality
*
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Please describe how this program/service addresses the SDOH of
Education Access and Quality.
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36
Social Determinants of Health - Social and Community Context
*
This field is required.
Please describe how this program/service addresses the SDOH of
Social and Community Context.
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37
Social Determinants of Health - Healthcare Access and Quality
*
This field is required.
Please describe how this program/service addresses the SDOH of
Healthcare Access & Quality
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38
Social Determinants of Health - Neighborhood and Built Environment
*
This field is required.
Please describe how this program/service addresses the SDOH of
Neighborhood & Built Environment.
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39
Statement of Need/Problem
*
This field is required.
Discuss the need for the proposed program or service within the District. The need you address must clearly relate to your organization's mission and purpose. It should focus on the people you serve, not organizational needs, and it should be well supported by evidence and trends within your service sector. Identify which social determinants of health are addressed within this need. Include qualitative and quantitative data that support your argument, as well as relevant statistics and research, to demonstrate why this is a need in the District. You may use the link option to point to pertinent online resources, however the links will not be accessible by the reviewers.
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40
How are other organizations addressing this need in the community?
*
This field is required.
What other organizations within the community offer similar programs/services that address this need? Explain why your organization's provision of this program/service is different from or compliments offerings from other providers.
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41
Program/Services Description - Program Entry & Follow Up
*
This field is required.
Concisely outline how recipients enter the program. How are participants enrolled or connected to the program? Briefly describe how recipients come to learn about your program. What follow up, if any, is provided to the participant post intervention/service? If no follow up services are offered, explain how the impact of the intervention is determined.
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42
Program/Services Description - Program Activities
*
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Describe or define what interventions or services they receive. Describe what the service/program does to assist the participant. Explain how this service/program is beneficial.
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43
Program Goal
*
This field is required.
What is the program goal? Be clear in defining how the goal(s) relate to how the program addresses the need. Please outline the goal(s) utilizing the SMART methodology.
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44
Program Objectives & Measurable Outcomes
*
This field is required.
Please describe the objectives of how this program will meet its goal - as outlined above. Be clear in defining how each objective serves the goal. Keep in mind that your objectives should be specific and concise - provides the “who” and “what” of program activities. Defines the "what" that will be measured and the "how" of the outcomes as it relates to the provision of the program. What quantitative information will you be gathering and reporting as it relates to the impact of your program's services. Explain how the success of the program’s interventions or services for each objective will be measured.
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45
Organization Collaborations
*
This field is required.
Active collaboration is demonstrated by specific ongoing actions that benefit two or more organizations. Explain how this collaboration provides support for this program or service. These collaborations may be already established or initiated within the grant cycle. Applications with established or planned collaborations will receive greater consideration. Please do not list funders or other financial supporters who are not directly involved in the provision of the service/program.
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46
Anticipated Acknowledgment
*
This field is required.
Please select the methods by which the Organization will acknowledge the District's investment of funding.
Social Media Postings
Signage at Service Sites
Print Materials to Service Recipients
Website Display
Other
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47
Anticipated Acknowledgment
*
This field is required.
Please explain how the District's name or logo will be promoted. If social media is selected, please identify which platforms your organization utilizes.
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48
Funding History
*
This field is required.
Have grant funds awarded to your organization for this program ever been withdrawn, reduced or discontinued?
YES
NO
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49
Funding History - withdrawn, reduced or discontinued explained
Please explain why funding was withdrawn, reduced or discontinued.
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50
Program Budget
*
This field is required.
Please upload the Program Budget & Narrative file. Use the District provided spreadsheet which can be found here https://www.fallbrookhealth.org/community-health-contract-grants. *PLEASE NOTE - you will need this form for reporting.
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51
Terms and Conditions
*
This field is required.
Checking this box certifies that all information presented in, or attached to this application is complete and accurate.
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52
Authorized Signature
*
This field is required.
Please sign the application
Clear
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FY 2025.2026 Fallbrook Regional Health District Community Health Contract Grant Application
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