AHMC HEALTH FOUNDATION

Grants Program

Application

Enhancing the Health and Wellbeing of Our Communities

Grant Application Guidelines

Thank you for your interest in applying for a grant. Please follow the instructions below when submitting a grant application:

Step 1: Complete the Applicant Cover Page

Step 2: Attach a narrative, not to exceed 3 pages in length. Include the following information in the narrative:

¨  A Brief Introduction of Your Organization (Mission, History and any information you feel is relevant to this application)

¨  Description of the program or project

¨  Description of the population to be served (including number of people to be served)

¨  The expected outcome or goal of the program or project

¨  Description of how the effectiveness of the program or project will be measured

¨  Description of how the program or project will improve health or well-being or the target population

Step 3: Complete the Program / Project Budget Worksheet

Step 4: Attach a copy of the organization’s IRS determination letter of 501(c) 3 and Tax Identification Number (W-9 Form)

Step 5: Mail the completed application and supporting documents to:

AHMC Health Foundation

438 W. Las Tunas Drive

San Gabriel, CA 91776

Or, email the application and supporting documents to:

Step 6: For more information, contact: Eileen Diamond at (626) 457-3226

AHMC HEALTH FOUNDATION

GRANTS PROGRAM

APPLICANT COVER PAGE

1. Applicant Information

Name of Organization ______Tax ID# ______

Mailing Address ______

______

Contact Person ______Title ______

Phone ______Fax ______

Email: ______

2. Project or Program Information

Project or Program Title ______

Requested Amount $ ______

Please indicate the goal of the program or project:

_____ To support the delivery of healthcare services

_____ To promote health education

_____ To provide social services that will improve health and well being

AHMC HEALTH FOUNDATION

GRANTS PROGRAM

PROGRAM / PROJECT BUDGET WORKSHEET

(MUST BE SUBMITTED WITH PROPOSAL)

Name of Organization ______

Project Name ______

Total Project Budget $______

Amount requested $______

Revenue Sources for the Program / Project (please include any pending grants)

Source / Amount
$
$
$
$
Total / $

Expenses for the Program / Project

Amount requested from the AHMC Health Foundation / Amount to be funded by other sources / Total budget from all sources
Labor costs
Please specify positions to be funded / $ / $ / $
Equipment / $ / $ / $
Educational materials / $ / $ / $
Other (please specify) / $ / $ / $
Total expenses / $ / $ / $