Online Grant Application

Encompass Cares Foundation

Medical Missions Grant Application

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.

Today's Date*	Medical Mission Start Date*
	Medical Mission End Date*
Destination Country*
First Name*	Last Name*
Address*
City*	State*
Zip Code*
Home Phone*	Work phone
Fax
E-mail address
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Encompass Relationship Status (check one)
Encompass Employee?	ClinicalNon-Clinical
	Encompass Location
	Department
	Position
	Years at Encompass
	Hours per week
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Encompass Retiree?	Last Job Title
	Years at Encompass
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Community Partner?	Relationship
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Sponsoring Organization
Name of organization*
Contact person	Contact phone*
Contact Address*	City*
State	Zip Code*
Country	Fax
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Financial Need
Actual airfare cost*
Airfare request (maximum grant $750.00)*
Medical supplies request (maximum grant $250.00)*
Total grant request (maximum grant $1000)*
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Proposal Summary
Please describe this medical mission in narrative format, including: * Your personal goals * Your professional goals * Your responsibilities as a medical mission participant * Your motivation for being a volunteer

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You must retain receipts for airfare and medical supplies. Copies are required after your trip.
How did you hear about Encompass Cares?*


* Required

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