TPSF Emergency Relief/Recovery Funds Request Form

Use of this form is to request funds for emergency relief and recovery efforts conducted by physic aians and other child advocacy organizations in Texas during times of a natural disaster such as a hurricane, flood, fire, snow storm, earthquake and other emergency/disaster events.

(Limited funding is avaliable to TPS members that will be used for repair/replacement of items that are not covered by insurance, federal relief or other funds. Organizations that are Medicaid, CHIP, or indigent care providers who are directly impacting the health and well being of Texas children will be closely considered by the TPSF Board.)

Please provide a brief paragraph outlining your organization's purpose and mission.
Hospital, Nonprofit Organization, Medical School, etc.
Please give a detailed description on the proposed use of the funds requested.
Please upload a list of current Board of Directors (if applicable)
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc.
Please upload a copy of your organization's IRS Determination Letter (required only for 501 organizations)
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.