Applications must be completed and submitted by a professional healthcare provider. For grant consideration, please complete the following information and click SUBMIT.

Applications are subject to a Selection Committee and Board of Directors review. The Selection Committee meets on a monthly basis, at which time grant applications are reviewed. You will be notified in writing as to whether or not your request has been granted.

Select One No Yes A signed HIPAA-compliant patient authorization form is required to transfer patient's PHI to the Our365 Foundation Application Date 5/16/2012 Grant Recipient Information: Mr. Ms. Mrs. First Name Last Name Street Address City State/Province Zip/Postal Code -- AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon American Samoa Guam Daytime Phone Number () - Information on Recent Birth: Date of Birth / / Hospital City State/Province -- AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon American Samoa Guam Provide specific details in support of the grant request: List other means of financial assistance: Professional Healthcare Provider Information: Dr.   Mr.   Ms.   Mrs. First Name Last Name Title Email Hospital Name Hospital Street Address City State/Province Zip/Postal Code -- AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon American Samoa Guam Hospital Phone Number () - Hospital President Dr. Mr. Ms. Mrs. First Name Last Name