BMH Foundation for Community Health

Grant Application Form

Please complete and upload all information requested below. If you have any questions about this application, please contact Victor Farmer at 304-369-1230 xt 5522 or vfarmer@bmh.org.

Organization Information

Organization Name *

Organization Type * 🛈

501(c)(3)

Political Subdivision

Organization Tax ID or EIN *

Organization Street Address *

City *

State *

Zip *

Organization Website Address (if applicable) *

Contact Information

Organization Leader Name (First, Last) * 🛈

Organization Leader Title *

Organization Leader Phone *

Organization Leader Email Address *

Project Contact Person Name (First, Last) *

Project Contact Person Title *

Project Contact Person Phone *

Project Contact Person Email Address *

Project and Organization Background

Project Title *

Project Abstract * 🛈

Organization Mission/History * 🛈

Key Program Staff/Volunteers * 🛈

Project Financial and Timeline Information

Total Project Cost * 🛈

Total Amount Requested from the Boone Memorial Foundation for Healthy Living *

Are any other entities funding this project? * 🛈

Yes

No

Other Funding Requested

For every other entity funding this project, provide the entity name(s); amount funded; and whether the funding is committed or pending. *

Are any other entities providing in-kind resources for this project? * 🛈

Yes

No

For every other entity providing in-kind resources for this project, provide the entity name(s); resources committed; and and the estimated value of the resources. *

Please upload a detailed, line-item budget for this project. *

Please upload any third-party vendor quotes relating to this project (if applicable).

Please upload financial statements for your organization for the last two fiscal years. *

Projected Project Start Date: * +

Projected Project Completion Date: * +

Project Impact and Need Information

The BMH Foundation for Community Health supports and funds projects and programs which are designed to improve population health by addressing the social determinants of health. As recognized by the CDC, the social determinants of health include:

Healthcare Access and Quality: the connection between people's access to and understanding of health services and their own health. This includes access to health care, health insurance coverage and health literacy.
Education Access and Quality: the connection of education to health and wellbeing. This includes graduating from high school, enrollment in higher education, educational attainment, language and literacy, and early childhood education.
Social and Community Context: the connection between characteristics of the contexts within which people live, learn, work, and play, and their health and wellbeing. This includes cohesion within a community, civic participation, discrimination, conditions in the workplace, and incarceration.
Economic Stability: the connection between the financial resources people have (income, cost of living, and socioeconomic status) and their health. This includes issues such as poverty, employment, food security, and housing stability.
Neighborhood and Built Environment: the connection between where a person lives (housing, neighborhood, and environment) and their health and wellbeing. This includes quality of housing, access to transportation, availability of healthy foods, air and water quality, and neighborhood crime and violence

More information on the social determinants of health can be accessed at this link.

Please provide as much detail as possible in this section.

Which social determinants of health does your project address? (select all that apply) *

Provide a detailed description of how your project addresses healthcare access and quality. *

Provide a detailed description of how your project addresses education access and quality. *

Provide a detailed description of how your project addresses social and community context. *

Provide a detailed description of how your project addresses economic stability. *

Provide a detailed description of how your project addresses neighborhood and built environment. *

In addition to the information provided above, describe in detail why this project is needed. *

How many unduplicated people do you project to serve with this project? *

What tools or metrics will you use to measure the impact of this project? *

In the past five (5) years, have you applied for and have you received any other grants? If so, please detail from whom the grant was received, the amount, and what that grant was for. *

Upload any documents supporting your description of the impact or need for the project (optional).

Project Sustainability

Provide detailed information regarding your plan to sustain this project, including: how long you project this project or its outcome(s) to last; specific activities or processes you will implement to sustain the project or outcome(s); how the project or its outcomes will be funded during the projected sustainability period; additional partners that you will engage in the work; etc. *

Application Signature

By electronically signing this application, I hereby certify that all information provided is true and accurate to the best of my knowledge, and that I am authorized to submit this application on behalf of the organization listed. I acknowledge and understand that Boone Memorial Foundation for Healthy Living may deny my organization's request or grant my organization's request in whole or in part. I also understand that if my organization's request is granted, Boone Memorial Foundation for Healthy Living may impose certain conditions on the funding, which may include spending restrictions, reporting requirements, or other conditions. *

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Name of Person Signing Application *