Grant-Program Support Request - Healthy Charlotte Alliance

If you are applying for Program Support, please download and complete the following documents. Then save as PDFs and upload with the remaining attachments at the end of the application.

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:*
PROGRAM / PROJECT INFORMATION
Name of the program/project for which funding is being requested:*
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
Objective and background of the program/project.*
Reason this program/project is needed and how it benefits the health of the community.*
Please describe the population and geographic area served by this program/project.*
Annual number of Mecklenburg County residents to be served by this program/project.*
In what specific way will residents of Mecklenburg County be impacted by this program/project.*
Specific plans and timetable for this program/project.*
ADDITIONAL PROGRAM / PROJECT INFORMATION
Anticipated start date of the program/project:*
MM slash DD slash YYYY
Total budget for the program/project ($):*
Amount requested from Healthy Charlotte Alliance ($):*
Requested funds should be in the range of $10,000-$25,000.
Have funds been committed from other sources?*
- Yes
- No
If yes, please explain.
What are the current and long-term funding plans for the program/project?*
Describe how this program/project is unique in Mecklenburg County and why your organization is the most qualified to deliver the program effectively.*
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.
Date Signed:*
MM slash DD slash YYYY
Signature*
Please sign below with your mouse or finger (if using a touch screen).
FILE UPLOADS
Please include the following in PDF format:
1. The budget for the program/project for which you are applying. (Please download the Budget Template below and complete. Save as a PDF and upload with your other attachments.)
2. Organization’s overall operating budget.
3. A list of your Board of Directors
4. A copy of your organization’s official notice of tax-exempt status under the Internal Revenue Code.
5. Your organization’s most recent Form 990.
6. A brochure or printed material about your organization
7. Your program/project’s 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.
Program/Project Budget*
Please upload completed program/project budget template.
Accepted file types: pdf, Max. file size: 30 MB.
Operating Budget*
Your organization's overall operating budget.
Accepted file types: pdf, Max. file size: 30 MB.
Please download PROGRAM/PROJECT TEMPLATE and complete. Save as a PDF and upload
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 material about your organization
Accepted file types: pdf, Max. file size: 30 MB.
Please download EVALUATION PLAN and complete. Save as a PDF and upload your Evaluation Plan below.
Evaluation Plan*
Please upload your completed Evaluation Plan.
Accepted file types: pdf, Max. file size: 69 MB.
TROUBLE UPLOADING ATTACHMENTS?
If you have any trouble uploading your files, please email them directly to grants@healthycharlottealliance.org

CONTACT INFORMATION

PROGRAM / PROJECT INFORMATION

ADDITIONAL PROGRAM / PROJECT INFORMATION

FILE UPLOADS

TROUBLE UPLOADING ATTACHMENTS?