Disaster Relief Program Application

Section 1: Program Information

Program Name

NHSA Program Membership ID #

Head Start Director First Name

Head Start Director Last Name

Head Start Director Email

Head Start Director Phone Number

Program Address Line 1

Program Address Line 2

City

State

Postal Code

Country

Section 2: Disaster Relief Fund Request

Total Funds Requested (may not exceed $5,000)

Reason for needs of assistance (Letter of Request): This section must include the amount of funds requested, reason for your request, and description of natural disaster. The intent of the letter is not to be persuasive, but must address all concerns listed. 250 words minimum.

Evidence of Funding Needs: Please attach any receipts, invoices or insurance estimates to show evidence of funds needed. Also please attach any disaster from either county, state, or federal agency level ( e.g. FEMA).

Director Certification Form (Click here for fillable pdf. Please save and attach. This form must be completed for this application to be considered.

Electronic Signature

By submitting this form, I acknowledge the truthfulness of the information provided.

Full Name

Date