Columbia Gorge Health Council / PacificSource
Social Determinants of Health & Equity
Please complete each question below. You will NOT be able to save your work in this form and return to it. For a copy of the questions, look here.
Don't forget to submit the Budget form.
2) Please identify which 2020-2023 CHIP Priority(ies) this project addresses?

~ Housing


~ Food 


~ Transportation/Mobility


~ Improved access to equitable health care services

       - Dental    - Primary    - Behavioral    - Health Insurance     - Prevention/Promotion

~ Improved access to equitable physical activity and the outdoors

~ Improved Social Connection and Communication

       - Sense of Community     - Collaboration and Information Sharing

~Youth and Children

       - Youth Safety     - Early Childhood Development and Child Care

By submitting this application, I certify the following:

~  The above information is correct;

~  I am authorized by the governing board of this organization to submit this grant application

~  This organization is in good standing with the IRS, is tax-exempt, and if classified as 501(c)(3),

      it retains that status and is further classified as a public charity and not a private foundation;

~ This organization does not discriminate on the basis of ethnicity, color, religion, gender,      

      gender identity or expression, sexual orientation, physical circumstances, age, status as a

      veteran, or national origin.