Berks County Community Foundation-Community General Hospital Healthcare Fund Application

Community General Hospital Healthcare Fund Grant Application
This fund was established by the Community General Hospital Foundation to support a nonprofit hospital in Reading, educational activities related to rendering care to the sick and injured or to the promotion of health; scientific research related to the care of the sick in conjunction with a hospital operating in the City of Reading; and to promote the general health of the Berks County community.

In the past, grants provided funding for local childhood obesity programs, a countywide health needs assessment, a dental clinic, and a medical clinic.

In addition to submitting this application electronically, please mail the following additional information to Berks County Community Foundation, 237 Court Street, Reading, PA 19601:

A copy of your IRS determination letter, if applicable
A copy of your organization's most recently completed fiscal year audit or compliation
A copy of your organization's current operating budget

Organization requesting grant:

Contact Name:

Prefix	First	MI	Last	Suffix

Title (if applicable):

Street Address:

Address 2 (optional):

City:

State: Zip Code:
County:
Phone Number (xxx xxx-xxxx):

extension:

Fax Number (xxx xxx-xxxx):

Email address:

Organization's website address (if applicable):

Date (mm/dd/yyyy):

Are you a/an:

501(c)(3) organization
Individual
Church
School
Government Entity
Other

Program/Project Name:

Amount of Request (amount of money you are asking the CGH Fund for):

Total Project/Program Cost (Total cost including funding from other sources):

Purpose of Grant Request (one sentence):

Organizational Background
Please provide a brief history of your organization and its mission:

Provide an overview of your organizational structure:

Provide a brief explanation of the selection process for the board of directors and a list of current directors and their occupations:

Provide a brief explanation of your non-discrimination policy:

Program Information
Describe the specific program or project for which you are seeking funds by answering the following questions.

Provide a description of your program, including its goals and objectives?

How will the program operate?

Identify the healthcare issue/opportunity your program addresses:

Who, specifically, will your benefit from your program (demographically or geographically within Berks County)?

What are the expected outcomes for the above beneficiaries of your program?

How do you intend to measure the expected outcomes listed above?

Funding

What is the specific use of the program funds requested in this grant application?

What are your plans for obtaining other funding needed to carry out the program or project?

What are your plans for continued funding of the program if the program is expected to continue beyond the grant period?

Attach a budget worksheet that shows the project's expected income and expenses, including other sources of income. Note the specific expenses to be covered by these grant funds.

How did you hear about the Community Foundation?

REMINDER: Mail the following additional information to Berks County Community Foundation:

- A copy of your IRS determination letter, if applicable
- A copy of your organization's most recently completed fiscal year audit or compliation
- A copy of your organization's current operating budget