Online Mission Grant Application

Mission Grant Application

Today's Date:*

Mission Start Date*

Mission End Date*

Destination Country*

Country

Is this a medical mission?

Yes

No

Name:*

First

Last

Address:*

Street AddressCityState / Province / RegionPostal / Zip Code

Home Phone*

Area Code

-

Phone Number

Work phone

Area Code

-

Phone Number

Fax.

Area Code

-

Phone Number

E-mail address

1/5

Enhabit Home Health & Hospice Employee?*

Yes

No

Type of Employee

Clinical

Non-Clinical

Office Location

Department

Position

Years of Employment

Hours per Week

Enhabit Home Health & Hospice Retiree?*

Yes

No

Last Job Title

Years of Employment.

Community Partner?*

Yes

No

Relationship

Name of organization?*

Contact Person

Contact Address.

Street AddressCityState / Province / RegionPostal / Zip CodeCountry

U.S. Territories

Contact Phone:

Area Code

-

Phone Number

Fax

Area Code

-

Phone Number

Actual airfare cost*

Airfare request (maximum grant $750.00)*

Medical supplies request (maximum grant $250.00)*

Total grant request (maximum grant $1000)*

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?

Mission Grant Application

How to Serve