Nevola Fund Application | Maine-Dartmouth Family Medicine Residency

Nevola Fund Application

Thank you for your interest in the Nevola Small Grants Program. Please complete the form below to apply online and a member of the Nevola Fund Committee will be in touch with you about your application.

Nevola Fund Application Form

Application Date

Name of Applicant(s)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Anticipated Event/Project Date(s)

Project Details

Explain how this project relates to Nevola subjects (spirituality, humanity in medicine, clinician self-care and wellness)

Amount requested (please send quote to Barbara.Moss@mainegeneral.org)

Please list other funding sources for your event/project (either secured or applied for)

How will this event/project benefit central Maine?

How does this event/project relate to the mission of MDFMR? (please see www.mainedartmouth.org to review) How will MDFMR residents be invited to participate?

Who will be involved in organizing this project? Please list names of any collaborators within the residency and partners in the community.

Section Break

You may be asked to present findings or lessons learned once the event/project is complete.

Please type your name below to indicate your signature on this form.

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