Community Impact Grant for Community Health Centers Application Form

Community Health Center Grant

To learn more about eligibility and scope of the Community Health Centers Grants click here.

To apply for the 2019 Medline Community Impact Grant Program for Community Health Centers (round 2) please fill out the application form below:
Name of organization*
Must be a 501(c)(3) organization
W9 upload
Accepted file types: pdf.
Please upload your completed W9 in pdf format. Must not exceed 10mb
Organization address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Organization phone*
Executive director’s name*
Executive director’s email*
Primary contact name*
Primary contact email*
Primary contact phone*
Brief statement of your history, vision and goals*
(not to exceed 500 words/2500 characters)
Brief statement of the services and programs*
(not to exceed 500 words/2500 characters)
How many people are on staff, including volunteers?*
(use number format)
What are the patient demographics?*
(not to exceed 500 words/2500 characters)

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What is the annual budget and current funding sources (e.g., grants versus patients)?*
(not to exceed 500 words/2500 characters)
Please describe the program to be funded including goals, objectives, intended outcomes and timeline*
(not to exceed 500 words/2500 characters)
Please briefly describe the challenge or problem that exists and how the program addresses that problem.*
(not to exceed 500 words/2500 characters)
Please describe the audience to be served by this program*
(not to exceed 500 words/2500 characters)
Please describe how success of the program will be evaluated.*
(not to exceed 500 words/2500 characters)
Is this a new program?*
Please indicate how long the program has been in operation*
What are the most recent and significant outcomes?*
(not to exceed 500 words/2500 characters)
Grant amount requested*
What is the total cost of the described program?*
Please provide a list of significant funders and amounts.*
Add up to 5 columns by clicking the plus icon on the right.
Funder Amount
If you want to expand on any of the previous questions, use this space.
(not to exceed 1000 words/5000 characters)

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Include a letter signed by the CEO, President or a member of the Board, of the requesting organization endorsing the grant request.*
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, appdocx.
File types accepted: pdf, doc, docx, jpg, gif, png,
List of personnel who will be responsible for completion of this project, including title and email, and if the position is paid or volunteer*
Add up to 5 columns by clicking the plus icon.
Full Name Title Email Paid / Volunteer
The information I provided on and in connection with the Medline grant application is true, accurate and complete.
- I agree

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Funder	Amount

Full Name	Title	Email	Paid / Volunteer