INSTRUCTIONS

Before completing this application read the 2018 FMPC Grant Award FAQs & Guidelines, located at www.aafpfoundation.org/fmpc (click on FMPC Grant Awards Program). This Website also contains Sample Grants from top-scoring applications. This APPLICATION is a locked Word document. Your answer can be typed directly into the shaded box, or you can “cut and paste” your answer from another document into the shaded box. Typing the answer in a separate document will allow you to spell check and count your words. A note of caution: the format may change once pasted into the shaded box, so be sure to check! Any part of this application may be submitted as a separate attachment; however, the length of the application plus all attachments must not exceed 10 pages. Email completed application materials to . Application deadline is midnight Central Time, June 15, 2018. Questions? Call 800-274-2237 ext 4406 or send email to the address above.

I.  APPLICANT INFORMATION

NAME OF APPLICANT: Formal name of Chapter or Chapter Foundation that is applying

CHAPTER EXECUTIVE INFORMATION: Name, title, email, phone, mailing address

PROJECT CONTACT INFORMATION (if different than above): Name, title, email, phone, mailing address

PROJECT TITLE (8 words or less). Titles that describe the project are best.

II.  PROJECT SUMMARY

FMPC PRIORITY AREA (Select only ONE; if more than one applies pick the ONE that best reflects the PRIMARY focus):

Student-Resident Project (Focus is on education, research, and/or humanitarian opportunities for students (high school, undergraduate, or medical students) and/or Family Medicine residents.)

Member Outreach Project (Focus is on education, research, and/or humanitarian opportunities that target AAFP Family Physician members.)

Public Health Project (Focuses is on the health of families and communities by promoting healthy lifestyles; conducting research and/or providing education for disease and injury prevention; and/or projects that are humanitarian or service in nature that improve health of individuals or communities.)

Other Project (describe)

TYPE OF PROJECT (Select only ONE box below):

New Project (Refers to an innovative project, not just new to your chapter)

First Year Project (Refers to a project that is new to your chapter/foundation)
Existing Project that previously received FMPC funding Existing Project that has never received FMPC funding

AMOUNT REQUESTED FROM FMPC (round to the nearest dollar): $

PROJECT PERIOD: Provide the start date and end date for the project (or program) that you are seeking funding for?

Start date: End date:

EXECUTIVE SUMMARY (300 words or less): Summary description and what you want it to achieve. Include major milestones and time frames.

III.  PROJECT DESCRIPTION

TARGET AUDIENCE (200 words or less): Who are your participants and how many will be impacted? How will you bring this project to these participants?

PROBLEM/NEED STATEMENT (300 words or less): Include data and supporting information.

GOALS, OBJECTIVES, AND ACTIVITIES (No word limit but application plus attachments may not exceed 10 pages): For each goal you list, you must identify a corresponding objective and activity that will help you achieve the goal. Objectives and activities should be specific, measurable, attainable, relevant, and time-bound

EVALUATION TOOLS (300 words or less): What evaluation tools will you use to measure whether your project has achieved success? These evaluation tools should correspond to the goals, objectives, and activities stated in the question above.

PARTNERSHIPS COLLABORATION (200 words or less): Be specific. Will you have partners engaged in this project? If so, who? Will these partners provide money or in-kind resources?

IV.  ACHIEVEMENTS OF SIMILAR PROJECT PREVIOUSLY FUNDED BY FMPC

ONLY COMPLETE THIS SECTION IF THE CURRENT APPLICATION IS FOR A PROJECT THAT IS THE SAME OR SIMILAR TO ONE PREVIOUSLY FUNDED BY FMPC. DESCRIPTION (No word limit but application plus attachments may not exceed 10 pages): In addition to providing the achievements, this section should explain how the project you are currently applying for has been expanded or improved.

V.  PROJECT BUDGET – Note: % of FMPC Staffing and Administration cannot exceed 30%

FMPC REQUEST / OTHER FUNDING / IN-KIND or NON-CASH** / TOTAL BUDGET BY CATEGORY
STAFF & ADMIN Include all staff and personnel, interns, consultants, volunteers, members, etc. / $ / $ / $ / $
SUPPLIES / $ / $ / $ / $
EQUIPMENT / $ / $ / $ / $
OTHER / $ / $ / $ / $
TOTAL per Funding Source / $ / $ / $ / Grand Total
$
*% of FMPC Staffing & Admin Cannot exceed 30%*
(*Calculate using FMPC Staff & Admin/Total FMPC Funding) / *
%

*Staffing and Administration cost cannot exceed 30% of the FMPC Request.

**In-kind or non-cash donations can be goods, services or labor of people assigned to accomplish the project.

BUDGET NARRATIVE

(No word limit but application plus attachments may not exceed 10 pages): This section should be comprehensive and address funding requested from FMPC, as well as funding from other sources and in-kind support. For all categories please explain the need for the cost and how costs were estimated.

VI.  ATTACHMENTS

DESCRIPTION: For each attachment provide: a short description of the document, type of file (e.g., Word, PDF) and the total number of pages.

Application Deadline: Monday, June 15, 2018, midnight Central Time 2018 FMPC Grant Application - Page 2 of 2 Version 01.03.18