Delta Center California Intent to Apply

Applicant Information

Thank you for your interest in the Delta Center California Initiative.

We ask that each team indicates their intent to apply (one response per team). This action is non-binding; the purpose is to facilitate our planning for the review of applications.

Please contact deltacenterca@jsi.com with questions.

1. What is the name of the lead organization? (no acronyms please) *This question is required.

2. Who is the primary contact for the lead organization? *This question is required.

First Name

Last Name

Job Title

Email Address

Phone Number

3. Please write any additional email addresses for people who would like to be included in email communication about the Call for Applications.

4. What type of organization are you (i.e. health center, CBO, public hospital)?

5. Which of the following fields do you currently focus on (check all that apply)? *This question is required.

Physical Health
Mental Health
Substance Use Disorder
Other - Write In Please enter an 'other' value for this selection.

6. What are the names of your partners or partner organizations (if known)?

7. Would you like to be added to the Delta Center California email list for periodic updates about the initiative? *This question is required.