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Name*

Title

Phone

Email*

Name of Organization*

Organization Description*

What focus area(s) does your funding proposal apply to? (check all that apply)

Community Health Capacity

Vulnerable Older Adults

Young Children Impacted by Poverty

Which of our 16 counties do you serve? (check all that apply)

Allegany

Cattaraugus

Cayuga

Chautauqua

Cortland

Erie

Genesee

Herkimer

Madison

Niagara

Oneida

Onondaga

Orleans

Oswego

Tompkins

Wyoming

Briefly describe your project, what goals and outcomes you want to achieve, and how it benefits our target populations (500 words or less)*

Amount of funding requested*

How did you hear about us? (Check all that apply)*

Health Foundation staff

Referral (please indicate)

Online search

Media (newspaper, radio, etc.)

Social Media

Other (please list)

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