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• t "`w City of Santa Ana <br />F H Donation Request <br />City Manager's Office - M -31 <br />20 Clvlc Center Plaza <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />(714) 647 -5200 <br />wn <br />pp�; ig+iet a r�i #'s r. 'Yt ra - <br />a <br />Hilda Program <br />Address: 450 W. 4th Street <br />city, state, zip: Santa Ana, CA 92701 Phone: 714 -542 -7792 <br />Eman: hortiz @latinohealthaccess.org Fax: 714- 542 -4853 <br />Name: Latino Health Access <br />Tax - Exempt Status: Is your organization a non-prof ft or public tax - exempt organization as Select One: <br />defined under Section 501(c)(3) of the Internal Revenue Code? R Yes No <br />If No, you will only qualify for a credit for City- related costs for yourrequest (i.e. permit fees, If Yes, <br />staff time, rental rates for facilities or equipment, etc.),Costs for city services vary and if 33- 0562943 <br />approved, credit may or may not cover full cost of requested City services, ;Tax ID #: <br />City services Requested: $ 3 000 Date Needed: May 25, 2016 Mayor /Councilmember: iMartinez <br />Amount Requested: , I <br />Direct Payment Amount $3000 Event Date; 'Varies <br />Requested: 'Summer 2016 Event Time: <br />Event Location: <br />6 Santa Ana neighborhoods: Lacy, Eastside, Flower Park, Pico - Lowell, Bella <br />Address, City, State, Zip <br />Vista, New Horizons <br />' LHA will be working with residents in the 6 areas to develop resident leadership In creating healthier neighborhoods via <br />Description of <br />summer projects. These projects Include a Health and Resource Fair, Housing & Tenant Rights Education Fair, Traffic <br />:Event I Purpose: <br />Safety Education Campaign aimed at pedestrian families, Outdoor Movie NlghtsArts & Culture Fair. We will also be <br />housing interns from various universities through a Health Equity Fellowship program. Interns will interns to work <br />alongside residents to collect data, conduct door -lo -door outreach, and carry out community improvement projects. <br />Through the summer projects we aim to : <br />Activate publicspacos as open spaces; fits Includes streets, schools, school parking lots, ste (place making type projects) <br />C omm u n ity Be hell t: <br />- Creato family - oriented programming (one time or ongoing eunmler acgvtties)for all ages <br />Connect families to much needed Information and Sansone, Including health Insurance, monist homes, DI emotional wcllnose, housing <br />Applicant Signature: <br />j -.,��- r� Date: 5/51201 6 <br />Mail: City Manager's Office -M -31 Email: donationrequest @setnta- ana.org <br />20 Civic Center Plaza Fax: (714) 647 -6954 <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />Dor Ition Nerl'u'A;r, DR - <br />foum;il Mooting Btu,: <br />FJlgibility &1q1. YkS I NO Apptoved Antolini: <br />City h10 nngCl' S$Inetulr: Date: <br />Revised 11/1612015 <br />