Community Benefit Grant Application

Organization Details

Application Contact

Mailing Address

Program Details

Requested amount should range from $500 to no more than $8,000.

Please select between 1 to 3

Funding Category

Community Health Improvements - Community activities or programs that respond to community needs and seek to achieve objectives including; improving access to health services, enhance public health, advancing increased general knowledge.

Community Building Activity - Community-building activities improve the community's health and safety by addressing the root causes of health problems, such as poverty, homelessness, environmental hazards, etc. These activities strengthen the community’s health and social fabric, fostering collaboration, trust, and shared responsibility among residents. By empowering individuals and organizations to work together, these activities create a supportive environment that promotes long-term well-being, resilience, and sustainability, ultimately improving the overall quality of life for all community members.

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Program Approach

Is the purpose of this proposal clear and understandable? (2 sentences max.)

Define the target population for your initiative and how it will reach those that are most vulnerable to the health issue you are trying to improve. Please list the at-risk populations by geography (school districts, counties, zip codes), race, gender, age, disease, SDOH, health risk your program will target.

Please explain how you collect data such as number of individuals served, demographic data, etc. and what systems are used.

Please explain how you collect data such as number of individuals served, demographic data, etc. and what systems are used.

What evidence-based strategies are being utilized and how will it improve the health of the target population?

How will you measure the health improvement?

Identify the collaborating entities associated with this initiative. Please note any financial and/or in-kind contributions to your initiative.

Define your timetable for your initiative/program development, implementation, and measurement.

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Funding

In what ways will the grant funds be allocated to support your project? How will the grant funds be distributed across various components of your project, and what specific expenses will they cover?

Define your alternative plan if funding is not granted from Premier Health.

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Documents

Please upload the following documents related to your submission. Please upload documents in one of the following formats: pdf, doc, docx, ppt, pptx, ppsx, xls, xlsx

  1. IRS letter of determination 501(c)(3)
  2. Names of your organization's board members, terms of office and compensation, if any
  3. List of key staff members and your organizational chart
  4. Completed grant application form
  5. One example of each of the following (if available):
    • Annual report
    • Organizational brochure
    • A balance sheet and income statement covering your organization's most recently completed fiscal year
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Certify and Submit

You can review or modify your submission by using the "Return to Application" button below.