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Healthy Carolinians Partnership Support Initiative -Applicant Information Sheet (continued) <br />We have attached athree-year budget indicating expenses and revenues <br />consistent with the guidelines in the Initiative information sheet. <br />Our Fiscal year is July 1st to June 30th <br />Month Month <br />January 1, 200E December 31, ~ <br />Our Project year is to <br />Month Month <br />The following counties are included in our <br />Our ria •marv areas ofhealth-related program interests are: <br />CHECK ALL THAT APPLY <br />r Access to Health Care <br />r Chronic Disease <br />r Healthy Eyes <br />~ Health Promotion and Risk Reduction <br />r Infant Mortality <br />r Infectious Disease <br />r Injury Prevention and Control <br />>r Mental Health <br />1- Older Adults <br />>- Oral Health <br />l/ Other(s~ Specify. <br />Potential focus areas based on <br />Community Health Assessment: <br />- Environmental Health <br />- Risky Teen Behaviors <br />lv We have attached responses to the three application questions. (see page 3) <br />Please sign in the spaces provided below: <br />Executive Din;ctor Date <br />J Rosemary Summers, DrPH <br />Print/7'ype Name <br />Board Chair or other authorized signature Date <br />(Matthew Vizithum, O.D <br />Print/Type Name <br /> <br />Page 2 of 4 <br />