Take Action: Healthy People, Places, and Practices in Communities Project

COVER PAGE

FORM A

Tax ID Number:
Total Budget for Submitting Organization:

Proposal Contact:
Title of Contact (if applicable):
Email:
Phone Number:
Fax:

Total Amount Requested:

($2,000-$5,000)

This project is related to (check all that apply):

___ physical activity ___ nutrition/healthy eating

___ preventive screenings ___ healthy choices

Briefly describe your project in the space below:

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in the U.S. Department of Health and Human Services.

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