Project Name Amount Requesting Requesting Organization Organization Information Address Line 1 Address Line 2 City/Town State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Organization Phone and E-Mail E-Mail Phone Organization Fax Number Primary Contact Name Primary Contact Title Specific Geographic Area Served by Organization Brief Summary of Organization’s Function and Objective If this organization has received a prior Community Investment Fund grant or a donation from Froedtert Hospital in the past year, please describe project, funding level and date received. Availability of your services is restricted on the basis of race, sex, national origin or religion. Yes No Please explain the restriction. You refuse/restrict services to people unable to pay. Yes No You qualify as a not-for-profit organization under provisions of the Internal Revenue Code. Grant requests from individuals not accepted. Yes No Not applicable You will need to upload proof of IRS Certifications of 501(c)(3) status. Upload proof of IRS Certifications of 501(c)(3) status Upload One file only.256 MB limit.Allowed types: pdf, doc, docx, ppt, pptx, jpg, jpeg, gif, png. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. The organization is local and delivers services to populations residing in Froedtert Hospital’s Service Area. Yes No The organization is a unit of a national organization. Yes No National Organization Name Funding Request Summary Describe the agency requesting funds. Include its mission, populations served and how long the organization has been in existence. Briefly describe the project and how will funds requested be used for this project. Include a copy of project budget, target population and program goal(s). How does this project address the significant health needs identified in the Froedtert Hospital Community Health Needs Assessment or social drivers of health. Review the Froedtert Hospital Community Health Needs Assessment. Clearly state the anticipated/expected outcomes or results. Include measurable data. Describe the evaluation process and how results will be measured. Include timeline, data and/or tools/samples. How will this project collaborate with others to address needs that are similar and avoid duplication? Explain plans to ensure the sustainability of the program/project (if ongoing). Share any potential recognition opportunities if funding is received to promote the partnership and collaboration with Froedtert Hospital and Community Investment Fund. Supporting Documents Project Budget Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. W-9 Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. Members of the Board of Directors Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx, . There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. Most Recent Annual Report Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. CAPTCHA By clicking “next page” or “submit,” you agree to the processing and storage of your information in accordance with our Website Privacy Policy. While we take reasonable precautions to protect your data, please be aware that no internet transmission is completely secure. Your form data will not be delivered via e-mail or shared with unaffiliated third parties and will be removed from our website database after 90 days. Save Draft Submit