Grant-Operating Support Request - Healthy Charlotte Alliance

If you are applying for Operating Support, please download and complete the Operating Support EVALUATION PLAN. Save this document as a PDF and upload with your other attachments.

Operating Support – Application Overview

CONTACT INFORMATION
Date of Application*
MM slash DD slash YYYY
Name of Organization*
Address*
Street Address Address Line 2 City State ZIP Code
Phone number:*
Chief Administrative Officer:*
Name of person submitting this application:*
First Last
Email of person submitting this application:*
Phone of person submitting this application:*
ORGANIZATION INFORMATION
Select the investment priority which your organization most closely seeks to address. (choose only 1)*
- Mental health
- Access to care
- Chronic disease prevention
- Violence prevention
History and background of the organization.*
Reason this organization is needed and how it benefits the health of the community.*
Please describe the population and geographic area served by this organization.*
Annual number of Mecklenburg County residents to be served by this organization.*
In what specific way will residents of Mecklenburg County be impacted by the work of your organization?*
ADDITIONAL INFORMATION
Amount requested from Healthy Charlotte Alliance:*
Requested funds should be in the range of $10,000-$25,000.
If awarded, how will you use these funds to best support your operations in order to further your mission?*
Please list major sources of funding for your operations and at what level.*
What are the current and long-term funding plans for your organization?*
Are there other organizations doing similar work in the community? If so, in what way do you ensure no duplication of efforts?*
Describe how your organization’s efforts are unique in Mecklenburg County and why your organization is the most qualified to deliver the program effectively.*
Please describe the quantitative ways in which your organization measures the success of your program(s) as well as overall impact on the community.*
Briefly describe your marketing or communications plan to promote this grant award, if funded*
Describe opportunities for Healthy Charlotte Alliance members to engage with your organization.*
Please check below to indicate agreement:*
- By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if my organization is accepted as a grant recipient, any false statements, omissions or other misrepresentations made on this application may result in the rescinding of this grant by Healthy Charlotte Alliance.
Signature*
Please sign above with your mouse or finger (if using a touch screen).
Date Signed:*
MM slash DD slash YYYY
FILE UPLOADS
Please include the following in PDF format:
1. Organization’s overall operating budget.
2. A list of your Board of Directors.
3. A copy of your organization’s official notice of tax-exempt status under the Internal Revenue Code.
4. Your organization’s most recent Form 990.
5. A brochure or printed material about your organization.
6. Your Operating Support Evaluation Plan. (Please download the Evaluation Plan below and complete. Save as a PDF and upload with your other attachments.)

Please contact Erin Edwards (eedwards@healthycharlottealliance.org) with any questions.
Budget*
Your organization’s overall operating budget.
Accepted file types: pdf, Max. file size: 30 MB.
Board of Directors*
A list of your Board of Directors
Accepted file types: pdf, Max. file size: 30 MB.
Tax Exempt*
A copy of your organization’s official notice of tax-exempt status under the Internal Revenue Code
Accepted file types: pdf, Max. file size: 30 MB.
Form 990*
Your organization’s most recent Form 990
Accepted file types: pdf, Max. file size: 30 MB.
Brochure*
A brochure or printed descriptive material about your organization
Accepted file types: pdf, Max. file size: 30 MB.
Evaluation Plan*
Please upload your completed Evaluation Plan.
Accepted file types: pdf, Max. file size: 30 MB.
Please download EVALUATION PLAN and complete. Save as a PDF and upload
TROUBLE UPLOADING ATTACHMENTS?
If you have trouble uploading your files, you can email them directly to grants@healthycharlottealliance.org

CONTACT INFORMATION

ORGANIZATION INFORMATION

ADDITIONAL INFORMATION

FILE UPLOADS

TROUBLE UPLOADING ATTACHMENTS?