Qualtrics Survey | Qualtrics Experience Management

GRANT APPLICATION

Date of Application (mm/dd/yyyy):

Legal Name of Organization:

Year Founded:

Current Annual Operating Budget:

Executive Director:

Email:

Contact Person (if different):

Email:

Street Address:

City:

State:

Zip Code:

Website:

Phone:

Project Name:

Purpose:

Amount Requested:

Total Project Cost:

Beginning and Ending Dates of Project:

Geographic Areas to be Served (include zip codes):

1. Please provide a brief description of your organization and what it does.

2. Provide your organizations' mission and vision statements.

Identify the primary health need you hope to address and the population you are looking to serve through this grant.

Health Need:

Population Demographics (age, health condition, social/economic factors, etc.)

# of people that will be served:

Geography Served:

4. Project Plan and Goals: Describe how you plan to address the health need and how the money received will support your project.

5. Proposed Budget: List the items the grant will pay for.

6. Project Tracking: Identify how you are going to track project successes, people impacted, and the services delivered.

7. Partnerships: Identify other partners you have and how you will sustain this program when Johns Hopkins Health Plans grant funding ends.

Conflict of Interest Statement: It is the responsibility of every applicant to report a potential conflict of interest, which may consist of a direct or indirect financial gain or benefit to you or a family member. Please describe any potential conflict of interest in the space below. Any comments will be reviewed by Johns Hopkins Health Plans Compliance department.

Name and Title:

Signature and Date:

Organizations must meet the following criteria.

Organizations must be in the Maryland, Washington D.C., or Northern Virginia area
501(c) (3) status
Organizations most recent financial report or balance sheet must be provided with the application.
Organization’s project scope must align with a health-focused topic outlined in the RFP document.
If grant is awarded, the organization agrees to provide a project end update.
For additional questions about the grant criteria, contact Johns Hopkins Health Plans Community Relations team at CommunityRelations@jhhp.org.