donatebuttonpaypal
ethiopiacarrycinderblock

logo

Please complete all sections of this application.  Incomplete applications will be returned to the applicant, which may result in processing delays.  Please allow 30 days following the due date for grant notification.

Mission Grant Application

Today's Date:*
Mission Start Date*
Mission End Date*
Destination Country*
Name:*
Address:*
Home Phone*
-
Work phone
-
Fax.
-
E-mail address

Encompass/Homecare Homebase Relationship Status (check one)

Encompass Home Health Employee?*
Type of Employee
Office Location
Department
Position
Years of Employment
Hours per Week
Encompass Home Health Retiree?*
Last Job Title
Years of Employment.
Community Partner?*
Relationship

Sponsoring Organization

Name of organization?*
Contact Person
Contact Address.
U.S. Territories
Contact Phone:
-
Fax
-

Financial Need

Actual airfare cost*
Airfare request (maximum grant $750.00)*
Medical supplies request (maximum grant $250.00)*
Total grant request (maximum grant $1000)*

Proposal Summary

Please describe this mission in narrative format, including:
* Your personal goals
* Your professional goals
* Your responsibilities as a mission participant
* Your motivation for being a volunteer

Please describe this mission

You must retain receipts for airfare and medical supplies.  Copies are required after your trip.

How did you hear about Encompass Cares/HCHB Cares?