TEA Micro-Grant Opportunity for Pharmacogenomics Education

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* 1. Applicant Information

Name and Title of Applicant / Contact Person

Name of Church / Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Contact Phone Number

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* 2. Name of Pastor / Director

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* 3. Tax Status

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* 4. Tax ID / EIN Number

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* 5. Church / Organization website address

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* 6. Have you or someone from your church/organization attended a Taking Effective Action, Inc. (TEA) African American Pharmacogenomics and Precision Medicine Learning Event(s) (APPLES Program)?

Yes

No

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* 7. Briefly state your church/organization's health ministry or health/wellness committee's mission, goal, and/or objective(s). [state reason for applying if no health ministry/committee]

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* 8. Please tell us the approximate number of members your church or people your organization serves.

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* 9. Geographic area served

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* 10. If selected for this micro-grant opportunity, how many people would attend the required webinar/training?

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* 11. Approximate date your church/organization would host an APPLES event after receiving training/attending webinar

Date / Time

Date

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* 12. Approximate number of people you intend to reach

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* 13. How will you publicize your APPLES event?

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* 14. Briefly explain how you would sustain pharmacogenomics, precision medicine, and cardiovascular health education through your church, organization or as an individual.