Law Enforcement Health & Wellness Scholarship Application

1. Agency Information

Name of Agency*

Address (All Fields Required)*

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

2. Person Completing the Application

Name of Person Completing the Application*

Email Address*

Phone Number*

3. Number of Employees*

4. Please describe your agency's goals for meeting the health and wellness needs of your personnel.*

5. Please describe the health and wellness activities, programs or initiatives currently active in your department.*

6. Please describe your biggest challenge with implementing health and wellness activities, programs and/or initiatives within your department.*

7. On a scale of 1-5, rate how well your department is addressing the health and wellness needs of your personnel*

Not Well - Meeting No Needs
Minimally - Meeting Few Needs
Good - Meeting Most Needs
Very Well - Meeting Nearly All Needs
Excellent - Meeting All Needs

8. On a scale of 1-5, rate how comprehensive your agency's wellness program is.*

Not Comprehensive, No Current Program In Place
Minimally Comprehensive, Addresses 1-2 Areas of Wellness
Comprehensive, Addresses 3 Areas of Wellness
Very Comprehensive, Addresses More Than 3 Areas of Wellness
Fully Comprehensive, Addresses All Areas of Wellness

9. On a scale of 1-5, what level of impact are your department's current health and wellness activities, programs and/or initiatives having on your personnel?*

No Impact
Mild Impact
Moderate Impact
Notable Impact
Profound Impact

On a scale of 1-5, how satisfied do you think your personnel are with the current level of health and wellness activities, programs and/or initiatives in your department?*

Not Satisfied
Minimally Satisfied
Satisfied
Very Satisfied
Completely Satisfied

11. On a scale of 1-5, rate the impact you anticipate with the implementation the NCPCV/Lighthouse H&W Wellness Mobile App and Web-portal program.*

There Will Be No Impact
Minimally Impacted
Impacted
Very Impacted
Profoundly Impacted

12. Please indicate below your agreement should your agency be selected to receive a scholarship.*

We understand that the scholarships are sponsored by an outside funding source and agree to work with NCPCV & Lighthouse Health & Wellness to ensure that proper documentation is managed.
We agree to actively participate in the on-boarding process with project partners to ensure timely program implementation within 45 days of the start of the on-boarding process.
We agree to complete all program surveys within the requested time frame.
We agree to work with NCPCV & Lighthouse Health & Wellness to develop a plan for sustaining the program beyond the scholarship period.
We understand that this scholarship is for a service and there will be no actual monetary exchange between our agency and NCPCV & Lighthouse Health & Wellness. Program may continue without funding past month 12 but services and support may be limited.
We understand that the length of the scholarship is for 12 months of Lighthouse programming and NCPCV & Lighthouse Health & Wellness makes no financial commitment to program costs beyond this designated 12 month period.
We understand that once a scholarship is offered to our agency that we may decline to accept the scholarship.

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