Community Benefits Form

To inform Covenant HealthCare of any community benefits you or your department have provided, please complete this form.

Event Information

Date of Service
Description
Number of Events
Number of Persons Served
Department

Expenses

If no expenses were incurred for a particular category, enter 0. Please do not use currency symbols.

Direct Expenses ($)
Purchased Services ($)
Supplies ($)
Other Direct Expenses ($)
Staff Hours

Revenues

If no revenues were obtained for a particular category, enter 0. Please do not use currency symbols.

Fees ($)
Grants/Support ($)
Other Revenue ($)

Other Notes

Notes

Additional Event Information

Community Needs
Community Needs Partner
Setting
Other Setting
Format
Other Format
Target
Other Target
Gender
Targeted For:
Age Group

Contact Information

Submitted by
Phone
Your Vice President
Your Director