Healthcare & Nursing Education Foundation
HNEF Community Healthcare Grants
2016 Application Form
ORGANIZATION INFORMATION
Organization:
Website:
Mailing Address:
City:
State:
ZIP:
CONTACT INFORMATION
Contact Person for Grant:
Title:
Phone Number:
Fax Number:
Email Address:
BOARD OF DIRECTORS INFORMATION
Number of board members:
Percent who make a financial contribution to the organization:
PROPOSAL INFORMATION
Name of Program:
Amount of Request:
Program Type:
New Program
Geographic Area Served:
Brazoria
Harris
Collaborative Program?
If yes, list collaborating agencies:
Yes
Existing Program
Program Expansion
Fort Bend
Montgomery
Galveston,
Waller
No
PROGRAM INFORMATION
Program Description (500 word limit) – Provide an overview of the program, the services it
provides, and how it operates.
Target Population (250 word limit) – Describe the population the program intends to serve.
Community Need (250 word limit) – Describe the need in the community that this program will
address. Are there other service providers addressing the need?
Goals and Outcomes (350 word limit) – How many people will be served and how do you
expect them to be different as a result of this program?
Evaluation Methods (350 word limit) – How do you plan to measure the goals and outcomes
described above?
Other Funding – Please list other funding sources for this program, noting whether they are
potential, pending, or committed, as well as the amount requested or pledged.
Sustainability – If the organization does not receive the requested funding from HNEF, how will
the program proceed? If the program does receive funding from HNEF, how will the
organization continue to fund and operate this program when funding from HNEF ceases?
Recognition – How will the organization publicize HNEF’s support of the program?
BUDGET INFORMATION
Budget – Using the provided spreadsheet, complete a detailed line-item budget for the program.
Identify program revenues and expenses, clarifying the line items that will be supported by this
grant and the line items that will be supported by other funding sources. Use the provided
program staffing form to include a list of all staff positions participating in the program along
with salaries, fringe benefits, and percent to be funded by the grant. Budget information must be
submitted using the forms provided. Applications are subject to technical review and may be
disqualified if appropriate forms are not used.
Budget Narrative – Describe how the requested HNEF grant funds will be utilized. How will
this grant funding make a difference to the program?
REQUIRED ATTACHMENTS
Attachments – Please check that the following items are included in the proposal:
Email Paper (3 copies)
One-page cover letter
Completed application form
Completed program budget form and program staffing form
List of current Board of Directors
Copy of determination letter from the Internal Revenue Service
Copy of most recent audited financial statements and single audit reports
Current unaudited statement of financial position and statement of activities
Copy of most recent IRS form 990 (and extension request if applicable)