Online Community Assistance Application

Community Assistance Application

Community Assistance Application

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 Enhabit staff planning and participation.

Community Assistance Application

Today's Date:*

Community Assistance Start Date*

Community Assistance Program*

Name:*

First

Last

Address:*

CityState / Province / RegionPostal / Zip Code

E-mail*

Home Phone*

Area Code

Phone Number

1/4

Enhabit Relationship Status

Enhabit Employee?

Yes

Office Location

Department

Position

2/4

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

Name of organization?*

Contact Person

Contact Address*

Street AddressCityState / Province / RegionPostal / Zip Code

Contact Phone:

Area Code

Phone Number

Fax

Area Code

Phone Number

3/4

Financial Need

Total grant request*

Proposal Summary

Is there local office staff participation?*

Yes

Please describe what the funds would be used for in narrative format.*

Describe Enhabit staff participation:*

4/4

Community Assistance Application

Community Assistance Application

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