Application Form

To apply for funding please fill out the form below:

Contact Us

Your Name*
First Last
Your Phone*
Your Email*
Organization Information
Organization*
Phone*
Email*
Have you applied to Alberta Health Services for this equipment or request?*
* When do you need funding by?*
MM slash DD slash YYYY
* Please indicate the AHS response to your request?*
* Tell us more about what you are requesting funding for?*
* Tell us how this funding will help us to enhance healthcare in Cold Lake?*
Please include any supporting documents or attachments which indicate proof of previous declined requests from AHS or any other funders
Agreements*
- I agree this information provided is true and the organization you have indicated in the application is aware that you are submitting this request on its behalf
- I have the authority to bind the organization named in the application above
- I understand that by filling out this form I am consenting to being contacted by a member of Hearts for Healthcare and may be asked to present to a board commitee
Opted-in?
- I would like to sign up to the Heartbeat Newsletter so I never miss a beat about everything related to healthcare in Cold Lake
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