2022 NE District Convention Grant Application

Applicant Name(Required)

First Last

Applicant Job Title(Required)

Applicant Email(Required)

Facility/Program Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of individual to attend the 2022 IHCA Convention (If not applicant)

First Last

Individual's Email(Required)

Would this individual attend the Convention if this grant were not available?(Required)

Please share a brief description of why this individual should attend the IHCA Convention.(Required)