Community Service Grant Application

This application is a request for financial assistance and must be submitted by the chapter advisor or the chapter president.


Local chapters applying for Community Service Grant funds must be in good standing with the National Office. The Executive Council will not consider requests from chapters that are not in good standing.

Application Deadline: November 1 for consideration at the fall meeting; March 1 for consideration at the spring.

Filing Tip: Print this page and compile responses offline in a word processing file. Then return here and paste answers into this form.

Chapter Information:
Chapter/University Name
Chapter Address
Office Telephone Number
Fax Number
E-mail Address
Web Site Address
Chapter Advisor Information:
Chapter Advisor's Name
ASHA Membership Number
E-Mail Address
Co-Advisor's Name
ASHA Membership Number
E-Mail Address
Chapter Officer Information:
Chapter President's Name
NSSLHA Membership Number
E-mail Address
Chapter Vice-President's Name
NSSLHA Membership Number
E-mail Address
Region Number: (required)
 
Timeframe to consider this application: (required)
NOTE: Fall applications will be reviewed at the NSSLHA Council meeting in November and Spring applications will be reviewed at the NSSLHA Council meeting in March
 
Has this Chapter received a Community Service Grant in the past? (required)
If this chapter has received a Community Service Grant in the past, please indicate when the grant was received (fall or spring and year)
If awarded, the check should be made payable to: (required)
 

Project Description

Applicants are required to answer each question in this section.
Name of community organization designated to receive support:
 
Indicate date funds are needed:
 
Provide a clear and concise description of why the local chapter selected the organization to support and how the community service grant will benefit the organization:
 
Describe the equipment or materials that you will purchase with these monies. Please be specific. Include make and model of equipment, title and publisher of clinic materials, etc.
 
When and where will the organization be presented with your donation (in the event this application is funded)?
 
Who is the contact person at the organization your chapter wants to support?
Name
Title
Address
Phone Number
E-mail Address
Web Site Address
When and where will the organization be presented with your donation (in the event this application is funded)?
 
List all previous projects carried out by this NSSLHA Chapter: (if no previous projects have been completed, type "none")
 

Funding/Budget

Funding for Community Service grants is awarded as a matching funds grant. This means that NSSLHA will match funds raised by the local chapter up to $1,000.
Amount of support to be provided by your local NSSLHA chapter
Matching Funds you are requesting from the NSSLHA National Office
Total of the two amounts listed above
Please describe how the local chapter raised (or will raise) the matching funds for the grant award.
 

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