Rural Women Shaping Health Research Application Form

Rural Women Shaping Health Research

Building Capacity for Patient-Centered CER Among Rural Women
We strongly recommend downloading this Word document [LINK] and using it to draft your application before completing this online form. This will ensure you have a copy of your responses on file in case any technical issues arise and will help prevent the loss of information you have entered.

For full details about the project, visit [Link to the website page]

Have questions? Reach out at [PROJECT EMAIL] or join one of our open office hours - informal call where you can ask anything and get a feel for what the project involves:
- Friday, July 17 – 3:00–4:00 PM ET
- Thursday, July 30 – 11:00 AM–12:00 PM ET
- Monday, August 3 – 5:00–6:00 PM ET
To register for office hours, click this lin:

Join Office Hours
Application Form
About your Grange:
Name of your Grange
Number of your Grange
Location of your Grange

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
About your Grange
Does your Grange have a Grange Hall?
How many Grange members you currently have?
What methods does your Grange currently use to communicate with members and the broader community? (check all that apply)

Other
Facebook Page of your Grange
Website of your Grange
How do you plan to promote the project and drive attendance at roundtables?
Describe your Grange's connections to local organizations - churches, senior centers, libraries, civic groups, etc.
Why does your Grange want to participate in this project, and what makes this feel relevant or important to your community?
About Key Stakeholder
What is your Key Stakeholder's name?

First NameLast Name
Key Stakeholder email address
example@example.com
Is your Key Stakeholder 50 years old or older?
Where does your Key Stakeholder live?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your Key Stakeholder have reliable internet access and basic comfort with email and Zoom?
How long has your Key Stakeholder been a member of your Grange?
In her own words — why does she want to be part of this project?
Contacts
Name of your Grange President

First NameLast Name
Email of Your Grange President
example@example.com
Phone number of your Grange President
Please enter a valid phone number.Format: (000) 000-0000.
Primary point of contact for this application

First NameLast Name
Email of primary point of contact for this application
example@example.com
Phone number of primary point of contact for this application
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Rural Women Shaping Health Research

Application Form

About your Grange:

About Key Stakeholder

Contacts