PCF Request Form – Niagara Health Foundation

PCF Request Form

PCF Request FormFranziska Emslie2026-04-02T11:11:28-04:00

Applicant Information

Applicant Name

Applicant Title

Department

Site

Applicant Phone Number/Extension

Applicant Email

Request Information

Description of Item(s) or Initiative

Expected Patient Benefit(s)

Please include examples of other similar programs or items at other hospitals where applicable.

Estimated # of Patients Impacted

Which of the Six Key Elements of the Patient Experience will this request address?

Please provide a brief explanation of how this request will support this key element:

Amount Requested

Breakdown of Amount Requested

If you would like to tell us how you calculated your requested amount in more detail, please do so here.

Funding or (if

Quote(s) (if applicable)

Drag & Drop Files, Choose Files to Upload

Approval

Funding Confirmation

I confirm this request is not and can not be funded through operational budgets or existing programs

Director Approval Name

Director Approval Email

Director Phone #/Extension

Let’s Stay Connected

Enter your name and email below to join receive our monthly email newsletter. Each month, we’ll highlight some of the best moments at the Foundation in the previous month, along with upcoming event and campaign information.

By submitting this form, you are consenting to receive marketing emails from: . You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

By submitting this form, you are consenting to receive marketing emails from: Niagara Health Foundation. You can revoke your consent to receive emails at any time by using the unsubscribe link, found at the bottom of every email.

Let’s Stay Connected

Enter your name and email below to join receive our monthly email newsletter. Each month, we’ll highlight some of the best moments at the Foundation in the previous month, along with upcoming event and campaign information.

By submitting this form, you are consenting to receive marketing emails from: . You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

By submitting this form, you are consenting to receive marketing emails from: Niagara Health Foundation. You can revoke your consent to receive emails at any time by using the unsubscribe link, found at the bottom of every email.

Niagara Health Foundation
1200 Fourth Ave
St. Catharines, ON
L2S 0A9

Contact Us
905-323-3863
foundation@niagarahealth.on.ca

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