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*
Is this a medical mission?
Home Phone*
Work phone
E-mail address

Encompass Health Relationship Status (check one)

Enhabit Home Health & Hospice Employee?*
Type of Employee
Office Location
Years of Employment
Hours per Week
Enhabit Home Health & Hospice Retiree?*
Last Job Title
Years of Employment.
Community Partner?*

Sponsoring Organization

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

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
Describe medical component to mission trip (required):*

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

Enter the characters from the box:
How did you hear about Enhabit Cares?