Health Center Information:
Name of Health Center:________________________________________________
Address of Health Center:______________________________________________
Applicant Information:
Name of Applicant:____________________________________________________
Position of Applicant:__________________________________________________
E-mail of Applicant:____________________________________________________
Phone Number of Applicant:____________________________________________
Funding Request:
Summary – Add an attached description of your funding request.
Please use 150 words or less.
Amount Requested:_________________
Maximum request is $5,000.
Other Sources of Revenue for This Project:
List in attachment.
Deadline: October 31, 2017
Submit to: Healthy Houston Foundation
1770 Saint James Place, Suite 250
Houston, Texas 77056
Applicant’s Signature:____________________________________________________
Date:__________________