"Emergency Medical Services Children Grant Application Form" - Nevada

Emergency Medical Services Children Grant Application Form is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • Released on August 1, 2014;
  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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STATE OF NEVADA
Department of Public and Behavioral Health
Emergency Medical System Program
4150 TECHNOLOGY WAY, SUITE 101
CARSON CITY, NEVADA 89706
(775) 687-7590
Emergency Medical Services Children Grant
This Grant is be used for pediatric training or equipment
Please complete the following application by typing or printing clearly.
Agency Name
:
Training to be conducted or Equipment requested: _____________________________________________________________________________
______________________________________________________________________________________________________________________
Amount of funding requested: $
:
Propose of grant
Equipment
Training
Local Government Agency to receive and administer the funds (If different from above)
: ________________________________________________________
Address
:
(Street)
(City)
(State)
(Zip)
(Tax I.D. #)
Authorized Local Official
:
(Print Name)
Authorized Local Officia
Date:
l:
(Signature)
Training Program Coordinator
:
Address
:
(Street)
(City)
(State)
(Zip)
Email address: __________________________________________________________ Daytime Phone #: ______________________________
In addition to this application please submit (on agency letterhead) a brief explanation of the need for this training program or equipment and; the
following information:
Scope of Work: Needs to include a description or outline of the educational program to be conducted with a list of goals and objectives. For
equipment request, need to include a full detailed description of equipment, how the equipment will be used and the impact Nevada.
The number of EMS personnel expected to participate in the training (for training only)
A brief description of the geographic area to be served by the training or equipment.
A detailed budget that shows the total costs of the training program or equipment.
Submit application and required documentation to:
Division of Public and Behavioral Health
EMS Program- Attention: Connie McFadden
4150 Technology Way, Suite 101
Carson City NV 89706
Fax: (775) 687-7595
EMS Office Use Only
Date Received:
Reviewed By:
EMS Program Director: ___________________________________
Approved
Denied
Date: _________________________
Amount Authorized: $ __________________________________ Budget/Category: ______________________________________________
Revised Aug 2014
Page 1
STATE OF NEVADA
Department of Public and Behavioral Health
Emergency Medical System Program
4150 TECHNOLOGY WAY, SUITE 101
CARSON CITY, NEVADA 89706
(775) 687-7590
Emergency Medical Services Children Grant
This Grant is be used for pediatric training or equipment
Please complete the following application by typing or printing clearly.
Agency Name
:
Training to be conducted or Equipment requested: _____________________________________________________________________________
______________________________________________________________________________________________________________________
Amount of funding requested: $
:
Propose of grant
Equipment
Training
Local Government Agency to receive and administer the funds (If different from above)
: ________________________________________________________
Address
:
(Street)
(City)
(State)
(Zip)
(Tax I.D. #)
Authorized Local Official
:
(Print Name)
Authorized Local Officia
Date:
l:
(Signature)
Training Program Coordinator
:
Address
:
(Street)
(City)
(State)
(Zip)
Email address: __________________________________________________________ Daytime Phone #: ______________________________
In addition to this application please submit (on agency letterhead) a brief explanation of the need for this training program or equipment and; the
following information:
Scope of Work: Needs to include a description or outline of the educational program to be conducted with a list of goals and objectives. For
equipment request, need to include a full detailed description of equipment, how the equipment will be used and the impact Nevada.
The number of EMS personnel expected to participate in the training (for training only)
A brief description of the geographic area to be served by the training or equipment.
A detailed budget that shows the total costs of the training program or equipment.
Submit application and required documentation to:
Division of Public and Behavioral Health
EMS Program- Attention: Connie McFadden
4150 Technology Way, Suite 101
Carson City NV 89706
Fax: (775) 687-7595
EMS Office Use Only
Date Received:
Reviewed By:
EMS Program Director: ___________________________________
Approved
Denied
Date: _________________________
Amount Authorized: $ __________________________________ Budget/Category: ______________________________________________
Revised Aug 2014
Page 1