Community Partnership FunD 2017GRANT Application

Using thistemplate, complete your application by answeringthe items below.

1 / Applicant Name/Title
2 / Applicant Email / Applicant Phone #
3 / Organization Name and
Website Address
4 / Project/Event Title
5 / a. Total Project Cost / b. CPF Funding Requested
6 /
  1. Is your organization a non-profit?
/ Yes No /
  1. If yes, please provide
tax-exempt code:
7 / Is this a single or multiyear project? / Single-year Multiyear
8 / Project/EventCategory:
(To be eligible, you must check at least one box.Check all boxes that apply)
Health & Wellness:
Support community health services, education, and prevention and wellness programs / Partnerships:
Leverage partnerships to address socioeconomic disadvantages that affect health / Capacity Building:
Improve community health through collaborative partnerships, economic and workforce development, and advocacy
9 / Briefly describe your organization’s mission statement, history, key services and service areas(s), target population, and locations, if applicable (Character Limit: 5000).
10 / What are your identified community needs? How do they align with Adventist HealthCare’s mission and priority areas? (behavioral health, cancer, diabetes, influenza, heart disease and stroke, maternal and child health) (Character Limit: 3000).
11 / Describe your project objectives, start and end dates, target population, and how many individuals will be served with the requested funding.(Character Limit: 1500).
12 / List the measureable goals for each objective. (Character Limit: 1500).
13 / Are other partners involved in this project? If yes, please list them here.
14 / Describe past outcomes of this project or indicate ‘Not Applicable’ (Character Limit: 3000).
15 / Describe plans for sponsorship acknowledgment (e.g., e-newsletters, press release, event announcements, website, use of logo, etc.)
16 / Other Funding (List all other funding sources for this project; include the funder’s name and amount received/pledged. If a source wishes to remain anonymous, please list the amount received/pledged.)
17 / Previous Community Partnership Support (If your organization has received past funding from the Adventist HealthCare Community Partnership Fund, list the project title[s], grant date[s], grant amount[s] and results or outcomes.)
18 / Board Member List. Please attach a list of current board members; if an AHC employee is currently serving on your board, provide the individual name(s) below.

*Please attach further documentation, such as flyers containing event information, sponsorship levels, relevant reports, etc.

For additional information and to submit your completed application, please email our Community Partnership Fund Coordinator at

CPF Grant Application for Funding Page 1 of 3

Community Partnership FUnd GRANT APPLICATION BUDGET

Using this one-page template, complete your budget below.

1 / Applicant Name/Title
2 / Organization Name
3 / Project/Event Title
4 / a. Total Project Cost / $ / b. CPF Funding Requested / $
5 / Percent of Annual Budget. What percent of your organization’s annual budget would the requested amount account for? / %
6 / Budget. Provide the proposed itemized/categorized costs as well as a brief justification for each item for the CPF Requested Funding or attach additional details if necessary.
Line Item: / Justification: / Dollar Amount:
a. / $
b. / $
c. / $
d. / $
e. / $
f. / $
g. / $
h. / $
i. / $
j. / $
Total Value / $

CPF-Project Budget (rev 6/16) Page 1 of 1