lease specify the amount of the requested contribution and/or specify the in-kind services requested.
In-Kind Services Requested:
____ Other: ______________
____ Hospital Personnel
EASON FOR REQUEST
lease choose the activity or program category(ies) that best match your request:
____ Charity event for not-for-profit community organization
(Information regarding your event must be submitted along with this application)
____ Fund for a local community clinic
____ Emergency funds for individuals in the community
____Community building activity (e.g., physical improvements and housing, economic
development, community support, environmental improvements, coalition building, community
health improvement advocacy, workforce development)
____ Non-local community requesting help for response to natural disasters
____ Community health improvement services benefitting persons living in poverty
____ Subsidized health services
____ Other: _________________________________________________________________
Describe how the
donated funds will be used to address a community need and benefit the health of the
community, and attach any additional information describing the activity or program that is the subject of this
request. Additionally, if applicable, explain how the intended use aligns with one or more of Northside’s
top seven (7) community needs identified on Appendix 1 to this Application.
Explain how this request aligns with Northside’s mission set forth on Appendix 1 to this Application.