Application for Mini-Grant

Inland Hospital

Thank you for your interest in Inland Hospital’s Community Benefit program. Requests using this electronic application are preferred. If electronic submission is not possible, please submit a typed copy of this application. Incomplete applications will not be considered. Attachments to this application are not necessary, but may be requested later. Applications are being accepted from October 8 – October 29, 2012 at 5 pm. Please complete this form and submit electronically or mail to: Tammy Poissonnier, Community Benefit Coordinator, 200 Kennedy Memorial Drive, Waterville, ME 04901 or email at tpoissonnier@emhs.org. For more information call 861-3392.

Section 1- Requesting organization information

Organization Name:
Organization Type:




Other:

Check the items you can provide upon request. Please do not attach to application.



Street Address:


City:
State:
Zip:
Telephone:
Fax:
Website:
CEO/Executive Director:
Contact person completing this application:
Contact person title:
Contact person phone:
Contact person email:
Funding Amount Requested:

Section 2-Project Specifics

 
Has your organization received funding from Inland in the past?




If yes, amount:

If yes, describe the last funded project its outcome, and did it meet your measurable goals? (200 words maximum).

What is your organization’s current annual operating budget?:
If your funding request is approved, how would the funds be used? Please break down your project/service budget and include any other funding sources.
   

1. Briefly describe your current project, program, or activity that our funding would support. (Include target audience and how many people will be impacted by this service/project.) (100 words maximum)

2. Describe and give examples of how this project/service will improve the quality of life in our area. Also, is your service/project “evidence-based"? (150 words maximum)
3. Describe and give examples of how you will measure the success of your project/service. Please note if there are others partnering or collaborating (involved) in this project/service. (100 words maximum.)

Section 3-*Signature(s)

 
Contact/Requestor's Email Signature:
* Above signature indicates all information submitted is accurate and valid.
Be sure to print or save a copy of this before selecting “Submit”. Once you submit you cannot retrieve or change your application.