Happy Healthy Hearts Application
This form is to be filled out by the individual or legal guardian who is applying for assistance from the Happy Healthy Heart program.  A Reference Form will also need to be filled out by an individual that qualifies as a reference.  Both forms will need to be submitted before your application can be processed.
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Email *
Participant Information
Date *
MM
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DD
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YYYY
Name (First, Last) *
Address *
City *
State *
Zip Code *
Phone # *
Can we text you? (We will not spam you!) *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Parent / Guardian Information (If under age 18)
Name of Parent / Guardian
Address of Parent / Guardian
Phone # of Parent / Guardian
Can we text you?
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Email Address of Parent / Guardian
Activity Information
What is the name of the program or activity you want to attend? *
What is the name of the organization you are signing up with ? *
Street address of the organization *
City *
State *
Zip Code *
Phone # of organization *
Email Address of point of contact (If known)
Website address (If known)
What is is the cost of the program or activity that you want to attend? *
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 that there is financial need and a grant from CCPRF is essential to me 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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This form was created inside of Crook County Parks and Recreation District.

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