CALIFORNIA SMALL FITNESS FACILITIES ASSOCIATION (CASFFA) COMMUNITY HEALTH MICRO-GRANT

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* 1. Full Name

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* 2. Email

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* 3. Legal Business Name

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* 4. Other Business Name (DBA)

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* 5. E-mail Address

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* 6. Phone Number

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* 7. Business Address

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* 8. Business Owner Name

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* 9. Business Owner Home Address

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* 10. Business Website

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* 11. Briefly describe the nature of your business (max 250 characters)

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* 12. Type of Business Entity

Corporation (C-corp, S-corp)

Limited Liability Company (LLC)

Partnership (LLP, Joint Venture)

Individual/Sole Proprietorship

Franchise

Nonprofit

Other (please specify)

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* 13. Number of Full-time Employees

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* 14. Number of Part-time Employees

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* 15. Describe how you intend to use the grant funds to provide a free or reduced rate health, wellness or fitness programs/services. Be as specific as possible.

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* 16. Describe the individuals that your program intends to help (for example; specific underserved groups, seniors, individuals with chronic diseases, childhood health services, mothers and families with limited resources, etc...)

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* 17. Federal Tax ID (EIN)

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* 18. If you are awarded the grant, who will the funds be dispersed to? Write the full name of a person who will be accepting the grant, or state the business entity name exactly as you would like it to appear on the check.

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* 19. As part of accepting the grant from the CASFFA, the applicant must agree to the established reporting requirements. Grantees will report to CASFFA to show:

1. A list of completed services at a reduced or discounted rate to the community.
2. Description of services provided.
3. Zip codes of participants.
4. 1-3 written or video testimonials from participants in the program.

Applicants must use the grant funds and report on the progress of the program by submitting the information above by May 31st 2022. By signing your name below, you accept the reporting requirements and understand that if you don't follow these requirements, you will be out of compliance. Write your name to agree.

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* 20. Describe how you intend to comply with the reporting requirements and track program progress, given the criteria in Question 19 (above).

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* 21. I certify that the information submitted in this application is true and correct.
I further understand that any false statements may result in denial or revocation of this grant. Write your full name below to agree.

CALIFORNIA SMALL FITNESS FACILITIES ASSOCIATION (CASFFA) COMMUNITY HEALTH MICRO-GRANT

Question Title

* 1. Full Name

Question Title

* 2. Email

Question Title

* 3. Legal Business Name

Question Title

* 4. Other Business Name (DBA)

Question Title

* 5. E-mail Address

Question Title

* 6. Phone Number

Question Title

* 7. Business Address

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* 8. Business Owner Name

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* 9. Business Owner Home Address

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* 10. Business Website

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* 11. Briefly describe the nature of your business (max 250 characters)

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* 12. Type of Business Entity

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* 13. Number of Full-time Employees

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* 14. Number of Part-time Employees

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* 15. Describe how you intend to use the grant funds to provide a free or reduced rate health, wellness or fitness programs/services. Be as specific as possible.

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* 16. Describe the individuals that your program intends to help (for example; specific underserved groups, seniors, individuals with chronic diseases, childhood health services, mothers and families with limited resources, etc...)

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* 17. Federal Tax ID (EIN)

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* 18. If you are awarded the grant, who will the funds be dispersed to? Write the full name of a person who will be accepting the grant, or state the business entity name exactly as you would like it to appear on the check.

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* 20. Describe how you intend to comply with the reporting requirements and track program progress, given the criteria in Question 19 (above).

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* 21. I certify that the information submitted in this application is true and correct. I further understand that any false statements may result in denial or revocation of this grant. Write your full name below to agree.

* 21. I certify that the information submitted in this application is true and correct.
I further understand that any false statements may result in denial or revocation of this grant. Write your full name below to agree.