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FACE SHEET <br />APPLICATION FOR FUNDS FOR <br />NATER;IAL AND CHILD HEALTH SPECIAL PROJECTS <br />'APPLICANT AGENCY <br />Name <br />Independent School <br />District 621 <br />REFERRAL' <br />FILE NONO.-&S 2L.1 <br />Address Phone (include area co• <br />2959 North Hamline Ave., St. Paul, MN 5511 (612) 636-3650 <br />PROJECT DIRECTOR <br />Fusan <br />me Address Phone (include areacoc• <br />Hagstrumtor of Special Services 2959 North Hamline Ave., St. Paul, MN 5511 (612) 636-3650 <br />CONTACT PERSON <br />Address Phone (include area cod' <br />Name i Mounds View High School (X-19 <br />Jean Norrbom, P.H.N. 1900 W. Co. Rd, F„ St. Paul, MN SS112 (612) 633-4031 <br />PROJECT INFOP,MATIOM <br />Date of application Title of project 'total MG:sP funds zeque:: <br />MCH Special Project <br />September 15 183 Chronic Absenteeism, from School 1 $105,000. <br />Date project to begin Date project to end71escent <br />al service children ages 5 - I: <br />I -I 84 12 31 85 Health Services (also services for <br />Health district and/or county(ies) served by this project: <br />Mounds View School District #621 (located within Ramsey County) <br />TYPE OF AGENCY .APPLYING (check one): <br />❑ Board of health ❑X Other <br />❑ Private non-profit organization ❑ Specify: School District <br />TYPE OF AGENCY ACTING AS FISCAL MANAGER (check one): <br />❑ Sbard of health © Other <br />❑ Private non-profit organization ❑ Specify: <br />COPIES OF THIS APPLICATION HAVE BEEN SENT TO THE FOLLOWING APPROPRIATE REVIEU AGENCIES: <br />.10ENCY Nkd (s) DATE SENT <br />ACENCY TYPE ,yone <br />Reglonal oevelopncnt <br />Ccentssion(s1 <br />Metropolitan Health Board <br />Health Systcm agency(lea) <br />Local Board(s) of llcoith I Ramsey County Board of Commissioners <br />(If applicant is not <br />a Board of Health) <br />AUTHORIZED OFFICIAL <br />Signature Irt} <br />Burton M. Nygren Superintendent <br />7Por .genesis other than jo-erwortal units, please attach evtdenre that apP <br />a recrrinlzed nonprofit institution or organization (501 C31. <br />9-15-83 <br />9-15-83 <br />pate <br />9pp <br />/13/B3I,, <br />is — <br />