Grant Application

Responsive multi-year grant applicants are encouraged to meet with the Foundation Director prior to submitting an application.

Note: For Community Health Excellence (CHE) grant applications, please use the CHE application and budget form instead. These are available online at PacificSource.com/che-program. The instructions are included with the CHE application.

Contact Information
Please tell us who to contact regarding your grant application.
Organization name: Contact name:
Tax ID number: Email:
Mailing address: Daytime phone:
City ST Zip:
Organization Overview
Describe your organization in one paragraph.
Program Description
Grant type: Responsive Strategic
Proposal is for a: One-year grant Multi-year grant
Title of program:
Amount requested (one-time or per year for multi-year proposals):
Total grant amount:
Grant period:
Program Overview
Goal
Describe the current challenges your organization targets and the major strategies undertaken to address these challenges. Summarize the related outcomes.
Demographic
Please describe the population and community/communities that will be served by your program. Please describe the ways you engage the community members you serve (i.e. program planning, member advisory boards, and satisfaction surveys).
Budget Narrative
Please describe how the grant dollars will be spent if received. List the funding you have already received and those funding sources. (Please clearly indicate committed and pending funds.) As appropriate, please specifically address your sustainability planning for continuation of these services/initiatives. Please provide your organization’s most recent audited financial statement and 990 forms.
Community
Who are you most important strategic partners? If you are a network, partnership or collaborative, describe your structure and how decisions get made. (If your network needs to build capacity or partnerships in order to complete the proposed work successfully, please include capacity-building or organizational development outcomes in the “Outcomes” section of this form).
Assessment
Please describe how you will measure and evaluate the success of your program/initiative.
Outcome
Please review the Priorities and Areas of Focus section of the application packet. Identify which priority area your proposal targets and identify at least one focus area your proposal will impact. In addition, please outline the specific outcome measures you will track in order to measure your success.
Quality Improvement
Please describe your organizational approach to quality improvement and continuous learning. Identify the current quality improvement processes underway.
Challenges
Please discuss potential challenges that could impact the achievement of your goal, such as internal or external changes in the environment. Describe your approach to mitigating these challenges.
Office Use Only
Approval: Yes No Date: Amount:

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