To allow adequate time for committee review, we suggest submitting your request 4-6 months prior to your deadline. Once your request has been reviewed, you will be notified of the committee’s decision. Organization Name Contact Name Name and Contact Information of Individual Making the Request Name Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip/Postal Code Email Reason for the Request Purpose Demographics of Those Served Does your organization support an under-served, under-represented or diverse population? Geographic Reach Attendance or Participation Does your organization directly impact the University, our students or UK HealthCare and our patients? Yes No If yes, please describe in detail the impact. Does your organization provide research funding to the University or UK HealthCare? Yes No If yes, please describe the type of research and the dollar amount of funding, if applicable. Have you worked with someone, other than the Community Engagement Manager within with University or UK Healthcare who has referred you? Yes No If yes, who? Please briefly describe your relationship with this person. Amount Requested If you are requesting a specific level of support, please indicate the amount here. Have you submitted any other requests from other departments within UK HealthCare or the University of Kentucky? Yes No If yes, who? Date Decision is Needed Note: Future consideration requires all organizations to report previous year's results along with submission. All requests will be evaluated based on alignment with UK HealthCare and/or the University of Kentucky strategic priorities. Supporting documentation Unlimited number of files can be uploaded to this field.256 MB limit.Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.