Happy Healthy Hearts Reference Form

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This form is to be filled out by the individual who is willing to act as a Reference for the individual who is applying for a HHH program grant. The individual who is applying for a grant must have an unbiased reference vouch for them that there is financial need and without this grant they would not be able to afford the desired activity or program. The information provided will be matched with their application and CCPRF staff will make a determination weather or not approve the request. Thank you for your willingness to act as a reference!

Email *

Reference Information

Date *

YYYY

Name (First, Last) *

Address *

City *

State *

Zip Code *

Phone # *

Can we text you? (We will not spam you!) *

Yes

Your professional relationship to applicant *

Participant Information

Name of Participant (First & Last) *

Activity Information

What is the name of the program or activity that the applicant wants to attend? *

What is the name of the organization they are signing up with ? *

What is is the cost of the program or activity? *

Why does this individual need financial assistance? *

Acknowlgement of the Terms and Conditions

By submitting this form I acknowledge that I have read and understand the terms and conditions of the Happy Healthy Heart Program. I agree on behalf of the above mentioned individual that there is financial need and a grant from CCPRF is essential to the applicant being able to participate in the proposed recreation program. I also agree to participate in a brief telephone follow-up if CCPRF deems necessary.

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