Please complete all sections of this application. Incomplete applications will not be processed. Please allow 30 days following the due date for grant notification. Projects must include local Encompass Health staff planning and participation.

Community Assistance Application

Today's Date:*
Community Assistance Start Date*
Community Assistance Program*
Name:*
Address:*
E-mail*
Home Phone*
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Encompass Relationship Status

Encompass Employee?
Office Location
Department
Position

Sponsoring Organization to Receive Funds or Support via this Community Assistance Application

Name of organization?*
Contact Person
Contact Address*
Contact Phone:
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Fax
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Financial Need

Total grant request*

Proposal Summary

Is there local office staff participation?*
Please describe what the funds would be used for in narrative format.*
Describe Encompass staff participation:*
Type the characters in the box: