Programs & Services: Community Outreach Request for Funding

Please complete this application. To submit, click on the button at the bottom of the page. The application will be forwarded to Lisa Lucas for processing. If you have any questions, please call Lisa Lucas at 734-615-6557.

Contact person:

Title:

Department:

Pager:

Address:

Phone:
E-mail:  

Title of project/event:

Description of activities:

Date of project/event:

 

Who is the target audience?

What are the objectives of the project/event?

How will you promote the event (flyers, radio, public service announcement, etc.)?

Will followup be done (is it required or desired)?

How do you plan to evaluate this program/event?

What benefits will the community experience from this event?

Amount of funding requested:

Please provide itemized budget for this event; briefly describe how you plan to utilize Community Health Services funding:
In the event of limited funds and/or high cost of the event, would you be able to secure partial funding if we could only provide partial funding?

What other agencies or organizations will contribute resources to this event? (Describe briefly.)

Additional comments

 

Submitted by:

Date:

Supervisor:

Department head: