Community Grant Application

Non-Profit/Organization Name:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Name *

First

Last

Email *

Mark your status, you must be one of the following categories. If you are a non-profit or if another non-profit that is your fiscal sponsor, please including documentation showing status and EIN (IRS letter): *

that evidence health

The Ottauquechee Health Foundation improves the health and well-being of people in need who live in the towns we serve. We do this through financial assistance, community partnerships, education opportunities, and support of wellness initiatives. How does your organization’s mission align with our mission?

How long have you been in operation?

Have you received a Community Grant from us in the past?

If yes, please list year(s) and amount(s):

Please give a brief description of the purpose of your grant request:

Who is the target population that will benefit from this grant?

What evidence or data supports the need for this project/initiative?

What specific health issues or risk factors are you addressing?

Please provide a timeframe including start date and end dates:

Anticipated number of people served:

What are the specific goals and measurable objectives? How will you measure success? What are your anticipated outcomes?

Amount of grant request (up to $5,000):

Please attach breakdown of costs. The allocation of grant money will be proportional to the number of towns and number of individuals in our catchment area.

Have you sought funds from other places? If yes, from where? Amount?

How do you plan to sustain the impact of this project beyond the funding period?

If your grant is approved your letter of agreement will ask for reporting based on your aforementioned measurable outcomes. Please expect e-mail check-ins from the executive director.