Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Basic Information – Step 1 of 8Legal Name of Organization *(Should be the same as on IRS determination letter and as supplied on IRS Form 990)EIN # of tax exemption designation under Section 501c3 *Please upload your W9 * Drag & Drop Files, Choose Files to Upload Organization Address Street *Line 2City *State *— Select State —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *County * Organization Contact Details Phone *FaxWebsite Contact Person Details First Name *Last Name *Title *Phone *Email *NextSave and Resume LaterPlease upload a list of Board of Directors and Officers * Drag & Drop Files, Choose Files to Upload Briefly summarize the mission of your organization and a brief description of your organization’s history. *(150 words)How does your mission align with the mission of the 1889 Foundation? *(150 words)Please upload your most recent audited annual financial statement Drag & Drop Files, Choose Files to Upload PreviousNextSave and Resume LaterAmount Requested *Name of Project *Impact Area (check all that apply) *Population HealthCollaborative projects promoting health and wellness for all ages – with a strong focus on disease prevention and healthy lifestyles.Mental and Behavioral HealthEmotional, psychological, and social well-being; the connection between behavior and one’s overall well-being. Together, mental, and behavioral health is a broad category that encompasses projects like mental health counseling and therapy, support for specific populations, such as bereaved children, at-risk children and youth, veterans, substance use treatment and prevention.Oral HealthThe state of the mouth, teeth and orofacial structures that enable individuals to perform essential functions such as eating, breathing, and speaking.Physical HealthProvides opportunities to build a healthy lifestyle through exercise and access to wellness activities, resources and access to health screenings and chronic disease prevention, and access to all forms of healthcare for people who are most at risk and underserved.Social Determinants of HealthNon-medical factors that influence health outcomes including food and nutrition, housing, transportation, employment, and social needs.Childhood DevelopmentThe growth of perceptual, emotional, intellectual, and behavioral capabilities and functioning during childhood. Childhood development is a broad category encompassing projects that help ensure children, from infancy all the way to the beginning of adulthood, are mentally and physically healthy, thriving in school, and provided with safe and wholesome opportunities to exercise and socialize.Medical Education and TrainingSupport for medical education and training to ensure our region has the medical professionals that are needed. Educate the community at large on a wide variety of 4 health related topics, provide training for specialized groups, and provide scholarships for the next generation of healthcare professionals.Description of the project *Identify the purpose of the project *Who will the project serve? (check all that apply) *All Age GroupsInfants (0-2)Children (3- 9)Preteens (10-12)Adolescents (13-18)Young Adults (19-25)Adults (26-64)Seniors (65+)Indicate the number of people the project will serve *Number of people *ActualEstimatedPlease identify which of the following long-term health outcomes your project will impact. (check all that apply) *Increased Life Expectancy – a longer average lifespan resulting from improved health behaviors, disease prevention, and access to quality healthcare, reflecting overall better population health and well-being.Improved Access to Healthcare – Greater availability, affordability, and utilization of timely, appropriate health services – especially for underserved populations – leading to earlier diagnosis, better management of chronic conditions, and improved health outcomes.Improved Childhood Outcomes – Enhanced physical, cognitive, emotional, and social development in children due to early access to healthcare, quality education, nutrition, and stable environments, setting the foundation for long- term health and well-being.PreviousNextSave and Resume LaterIs this project evidence-based, meaning is there research or data demonstrating its effectiveness? *YesNoPlease explainIndicators and MetricsWhat Quantitative measures: [e.g., screening rates, number of participants served, follow-up adherence] will be used to collect the information from your project? *What Qualitative measures: [e.g., participant surveys, focus groups, interviews, provider feedback] will be used to measure progress of your project? *What will be the frequency of collection to ensure data is consistent and reliable? *Baseline and TargetsPlease specify both baseline and target values for your outcomes. For example, “increase screening rates from 35% to 50% in 12 months.” *Include any additional outcomes you plan to achieve (e.g., improvements in knowledge, behavior, or access).Key Activities and TimelineDescribe the key activities that you will implement as part of your project to achieve these outcomes. *Include a timeline with action steps (e.g., Months 1–3, Months 4–6, Months 7–12). *Monitoring and AdjustmentHow often will you review progress (e.g., monthly, quarterly)? *What methods will you use to analyze data? *How will you use findings to adjust your strategies and ensure measurable impact? *How much impact does this issue have on the people who are affected? *Minimal Impact – Effects are minor or negligibleModerate Impact – Noticeable effects, but not severeSignificant Impact – Substantial consequences for those affectedCritical or Life-Threatening Impact – Severe, potentially life-altering or life-and-death consequencesWhat unique services would the community be deprived of if you did not undertake this project? Provide supporting data *To what extent does your organization have the necessary staffing capacity and expertise to carry out the project? Provide name, title, and brief summary of the qualifications of the key personnel for this project. *Specify your plans for sustainability of the project at the conclusion of the grant.To what extent will the impact of the project continue beyond this grant cycle? *How do you plan to continue measuring and demonstrating outcomes beyond the grant period? *List other financing sources or strategies that you are developing. *Are matching corporate or government funds available? *YesNoPlease list the amount and from whom. *PreviousNextSave and Resume Later For of use What collaborative relationships have been or will be formed with other organizations for this specific project? *1889 Foundation prioritizes collaborative, multi-organizational efforts.Please indicate how you plan to promote this program. *PrintRadioSocial media site(s)TVWebsite(s)OtherOther *PreviousNextSave and Resume Later List all sources of cash income for this project. Do NOT include in-kind support. Source *Check if SecuredSecuredValue * Total Project IncomePreviousNextSave and Resume Later List all expenses for this project. Expense *Value * Total Project ExpensesPreviousNextSave and Resume LaterAcknowledgementPlease keep in mind that although your project may appear to fall under our established guidelines, this Grant Application is for review purposes only. *By checking this box, I acknowledge that submitting this Grant Application does not guarantee funding.Form AuthorizationBy typing your name in the box below, you are authorizing that you have permission to apply for this grant on behalf of the organization. You also acknowledge that you are electronically signing this form. *SubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link
