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2. Directions:

   Complete all required fields below providing as much information as possible. 

   Applications will be reviewed on a monthly basis. Successful recipients will be notified via email. 

   Please note that completion of the application DOES NOT guarantee that your project/initiative will be approved for funding. Approval is dependent upon the availability of funds and the potential impact of your project/initiative compared to other submissions. 

6. Type of project/initiative?*
   -- Select One --IndividualDepartment
7. If individual, could this expense be covered by your insurance or FSA?
   -- Select One --YesNoUnsure
9. Name of project/initiative:
11. Description:*
13. Amount Requested:*

    ($200 maximum request)

14. Total Cost of project/initiative:*
18. Dimension(s) of Wellness Addressed:*

    Check all that apply:

    1. Emotional
    2. Financial

    1. Social
    2. Spiritual

    1. Occupational
    2. Physical

    1. Intellectual
    2. Environmental
20. Please describe how the project/initiative will address each dimension selected above:*
22. Supporting Documents
24. Comments:
26. First Name *
27. Last Name*
28. Email Address*
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field