Organization Information
Organization Name:
Organization Phone Number
Organization Website:
Contact Information
Contact Name:
Contact Phone Number:
Contact Email:
Confirm Email:
Are you a non-profit organization? (Current documentation is required.)
Do you have insurance? (Proof of valid insurance is required.)
Are you approved to request this project on behalf of the organization? (Proof may be required.)
Project Information
Project Title:
Project Description:
Estimated Cost of Project:
Do you need assistance with the cost of materials?
What is the estimated amount requested? Please be aware that HCCTP funds for assisting with materials are limited and are not guaranteed.
Physical Address of Project Site
Address Line 1:
Address Line 2:
City:
State:
Zip Code: