OHCF Senior Wish Program Funding Request

*(denotes required field)

Name:

Title:

Community Name:

Address:

City:

State:

Zip:

Email:

Phone:

Fax:

Senior Wish Details (include name(s) of resident(s) and a brief description of their condition and background, date of event, location, and how the wish came about):

List materials/resources/services required and the cost. (Note, be sure to research the most competitive price, if you cannot get the item/service donated):

What is your community providing toward the fulfillment of this wish (include dollar amount)?

What support are you seeking from the Foundation? (If financial, please list specific amount of your request and it’s use):

If your request for funding is granted, would you prefer:

A check prior to the event? If yes be sure to include the name that the check
is to be made payable to. Or
Reimbursement from receipts? Be sure to include receipts for reimbursement.

Have you previously attended a Senior Wish Training hosted by OHCF?:

Yes
No

In the event my funding request is granted I agree to recognize and credit the Oregon Health Care Foundation’s Senior Wish Program with facilitating this wish in all marketing materials, other communications pertinent to this event, and media coverage. I also agree to provide photos, photo release forms, and a summary of the Senior Wish project after its completion.

I Agree*

CAPTCHA Code:*