WellNXT Community Impact Grant Application

WellNXT Community Impact Grant Application

Application form for organizations applying to the WellNXT Community Impact Grant and booth participation at WellNXT NOLA x Fest 2026.
Applicant Contact Information
First Name
Last Name
Title / Role at Organization
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Organization Information
Official Organization Name
DBA / Commonly Known As
Employer Identification Number (EIN)
Nonprofit Designation / Status
Year Organization Was Founded
Organization Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parish / County
Organization Website
Primary Social Media Handle(s)
Organization Documentation
Upload Proof of Nonprofit Status

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Upload an Organizational One-Pager, Brochure, or Program Summary

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Organization Logo

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Mission, Programs, and Community Impact
Organization Mission Statement
Briefly describe your organization’s programs and services
What geographic area(s) does your organization primarily serve?

Other
If Other geographic area, please specify
Which of the following best describes your organization’s focus area?

Other
If Other focus area, please specify
How does your mission align with the WellNXT NOLA x Fest community?
Describe a recent community impact or success story
How many people does your organization serve annually?
Booth Participation and Logistics
Can your organization staff a booth for all three days of the event?
How many representatives will your organization bring to staff the booth?
What will you display or offer at your booth?
Do you have any setup or accessibility requirements we should know about?
Referral Source and Agreements
How did you hear about the WellNXT Community Impact Grant?

Other
Official Authorized Representative Certification
Accuracy of Information
Attendance Commitment
Marketing & Media Release
Rules & Regulations Agreement
Printed Name of Authorized Representative
Date

MonthDayYear
Date
Should be Empty:

WellNXT Community Impact Grant Application

Applicant Contact Information

Organization Information

Organization Documentation

Mission, Programs, and Community Impact

Booth Participation and Logistics

Referral Source and Agreements