General Information

Request Details

Describe the population(s) this will program target.
Describe the ways this request will improve health care outcomes.
Describe the problem or opportunity this grant will address.
Provide a summary of the request including specific goals and anticipated outcomes, as well as overall timeframe with major milestones.
Describe how this request will be implemented including all facilities, people, equipment, and materials that will be involved. Include major milestones and targeted completion date. Describe how outcomes will be measured.
If this request involves collaboration between organizations, please list each one and their role.
List major line items and funds or support being requested.
Describe the source of budget assumptions. Include a justification for the cost of the program, as well as an explanation as to how you arrived at estimated expenses and revenues, if applicable. If the program is to be ongoing, how will funding be sustained?
List any sources that you are aware of that could provide or could be interested in providing support for this proposal. This list could include individuals, local businesses, corporations, associations, charitable organizations, foundations as well as local, state, or federal funding sources.
Please add any additional information for the review committee to consider.

1. Attend at least one GRVHF Board meeting
2. Place GRVHF logo w/link on your website
3. Display tri-fold GRVHF info cards at organization location
4. Provide a silent auction item for the GRVHF annual event
5. Provide final report using GRVHF Final Report Template within 3 months of

I certify the information provided in this application is true and correct to the best of my knowledge. I understand that any false statements made herein will void this application and I will be ineligible for support from the GRVHF. I have read the eligibility requirements and certify that the proposed request is eligible. I also certify that I understand and agree to the grantee expectations, review process, timing, and criteria as stated in this application.
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