CYFD-BHS Fund Request Please enter in the information below. NMSU will contact you if we have any additional questions. Today's Date* Date Format: MM slash DD slash YYYY Your Name* First Last Your Email* Enter Email Confirm Email Your Phone*Please provide a number where you can be reached to answer questions related to your request.Grant Name*Please tell us which grant your request is related to. If you don't see your grant in the list, please select "other" to write it in.Healthy Transitions Expansion GrantSystems of CareService ArrayASURE-TIOtherOther funding source, please specifyIf none of the above categories fit your request please specify the funding source.Specific Project/Budget Line Item*To best of your knowledge list the line item this will be charged to. If you aren't sure put unknown. (example: YouthMOVE or Wraparound Training, or Governance Team Meeting)Type of Request*Please select the type of request below Purchase materials/supplies Participant stipend/allowance (check) Purchase light snacks (within state/federal guidelines) Other Other type of requestIf none of the above categories fit your request please specify the nature of your request.Date(s) of Event*If the request is not tied to a specific event, put "N/A"Time of Event (Start and end time)*If the request is not tied to a specific event, put "N/A"Event Location*If the request is not tied to a specific event, put "N/A"Estimated number of participants*Type of participantsList all the categories of participants who are involved with this event. Examples would be youth, families, JJ Staff, PS Staff, BHS Staff, Providers, etc. Participant Stipend/Allowance Request by Check DetailPlease provide a brief explanation about the purpose of these check(s).Information for check(s)*Please provide the following information for all participant allowance/stipend checks for this event/purpose. Please provide the complete address for the recipient.Full NameEmail AddressMailing AddressPhone NumberDollar Amount Material/ Supplies Purchase Request*What would you like to purchase? Briefly list what you are wanting to purchase and the quantity needed. Snack Purchase Request:*What would you like to purchase? If grant allows food, keep in mind that we cannot exceed $3 per person/day.Purpose:*Provide as much detail as is available regarding the purpose of the purchase and how it relates to the specific project. For purchases that are food related, a sign-in sheet or list of participants is required after the meeting/training.