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2025-2026 School Wellness Stipend Report Form

Reports are due no later than 2 weeks after the date of the event.

Please complete the form below to submit your report on your AtlantiCare Healthy Schools, Healthy Children supported wellness event.
  • Must include a 100-word minimum summary of how you utilized the funds
  • Must include at least 2 photos
  • Photos featuring students, school staff, and/or families must be accompanied with an AtlantiCare Photo/Media Release Form per individual
Reports are due no later than 2 weeks after your event with a final deadline of June 19, 2026 to be eligible for funding in the following school year.
1.School Name:(Required.)
2.School Address:(Required.)
3.Name of Person Completing Report:(Required.)
4.Email of Person Completing Report:(Required.)
Please provide an estimate of the demographics of students:
5.Provide an estimated percentage:(Required.)
6.Provide an estimated percentage:(Required.)
7.Age Group:(Required.)
8.Please provide a short summary of how you utilized the funds.
(100-word minimum)(Required.)
9.Please submit 2 photos that will highlight your efforts as a result of award received. Photos can include staff, students, and families engaged in your grant actions. The Healthy Schools team requests that all photos containing any individuals be accompanied by a completed AtlantiCare Media Release Form for every individual featured (including staff and other adults). Photos may be used for future publication. Upload Photo/Media Release below. All photos will become the property of AtlantiCare.

Upload Photo #1(Required.)
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10.Upload Photo/Media Release #1
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11.Upload Photo #2(Required.)
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12.Upload Photo/Media Release #2
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