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APPLICATION

Point of Contact Information

General Information

Letter of Recommendation

For the following questions, if an attachment will be provided, please write "Attached" in the form field.

Project Summary
In 300 words or less, provide an executive summary of the programing and/or projects that are most relevant to this year’s theme of health and wellness. This should show a proven record of achievement and extraordinary contributions towards betterment in the selected area. Please include:
     [1] The challenge the initiative is addressing
     [2] The innovative solution developed to address the issue

     [3] Other relevant data, if applicable (e.g., target demographic, milestones, objectives, partners, results, etc.)

Impact Statement 
Please indicate in 750 words or less how the organization or individual is improving health and wellness in the United States, particularly in regard to the following:
     [1] Breadth of impact, including geographic presence
     [2] Role as change agent
     [3] Collaboration among partners

     [4] Diversity of beneficiaries and Board/staff/volunteer representation, if applicable
     [5] Sustainability of the project.

Uploads

(Max 15MB each)

Recommendation Letter
IRS Determination Letter
Tax Return (990 or 990-EZ)
Financial Statement/Report
Impact Statement
Project Summary
Other
Other

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