FY 23-24 Full Grant Application - Grossmont Healthcare District

2023-2024 Full Grant Application

The following section contains instructions for completing a FULL grant application. A full grant application procedure is available to organizations seeking grants of more than $25,000. If you are requesting $25,000 or less, please complete a SIMPLIFIED grant application.

"*" indicates required fields

Contact Info

Legal Name of Organization*

Address*

Street Address Address Line 2 City State ZIP Code

Organization Website*

Organization Point of Contact*

First Last

Contact Email Address*

Proposed Project Title*

Amount of Funds Requested*

Anticipated number of GHD residents to be served*

Grant Application Summary

Attach a one page (500 words max) PDF including each of the following: description of proposed services, project site(s), target population(s), anticipated number of GHD residents to be served, community needs to be addressed, etc.*

Accepted file types: pdf, Max. file size: 50 MB.

Problem Statement, Agency Capability, Program Services and Evaluation Plan

Please limit your description to a total of five (5) single spaced pages (2500 words max). Please clearly identify all sections.

Problem Statement / Needs Assessment
If this grant application is being submitted for funding with a focus on a “Priority Community Health Need” (as described on page one (1) of the policy), which will assist in addressing one or more of the identified categories, please specifically discuss how the program is proposed to address such needs.

Please discuss the need for the proposed service(s) in the District. Discuss how the service is health-related, and not a duplication of existing services. Include quantitative and qualitative data documenting the unmet health needs.

Agency Capability (Please Describe Briefly)
1. Your organization’s history and accomplishments.
2. Your experience in the provision of services to the target population identified in your grant application.
3. What are the current activities and/or programs operated by your organization? An agency brochure may be attached.
4. List and describe cooperative and collaborative linkages with other organizations that enhance your ability to provide services.
5. Is the proposed program a new service that the agency will provide? Is this an established program that will be expanded to GHD residents?
6. Note any organizations or programs in the community that provide similar services, as well as whether you’ve taken any steps to collaborate with them.

Program Services and Evaluation Plan
1. What are the program goals and how do these goals specifically address the identified health need(s)?
2. What are the measurable objectives related to each goal? List specific outcomes and include timelines.
3. What kind of data will be measured and how will that data be collected?
4. How will the effectiveness of the program be assessed? How is quality controlled and monitored? Be specific.
5. How will the proposed program specifically fulfill the elements of the GHD mission statement? See our website for our Mission Statement.
6. How will participants access services? Describe the accessibility of the program site(s).
7. How will your agency generate referrals to the proposed program? How will services be marketed to participants?
8. What is the justification for any proposed equipment (if applicable)?
9. For those proposals that desire to be considered on such a basis, how does the proposal demonstrate a collaboration of like providers of service? (See page 4 of the Grants Policy for specifics and examples.)

Upload file:*

Accepted file types: pdf, Max. file size: 50 MB.

Budget

Project Budget Form*

Accepted file types: pdf, Max. file size: 50 MB.

Download, fill out, and upload the form as a PDF using the link below.

Project Budget Form to be uploaded can be found HERE.

All Budget Sources Form*

Accepted file types: pdf, Max. file size: 50 MB.

Download, fill out, and upload the form as a PDF using the link below.

All Budget Sources Form to be uploaded can be found HERE.

Supplemental Documentation

The following attachments are not required if your organization is a public agency.

Article of Incorporation

Accepted file types: pdf, Max. file size: 50 MB.

Not required if current version was submitted to the Grossmont Healthcare District in the last five years.

Bylaws

Accepted file types: pdf, Max. file size: 50 MB.

Not required if current version was submitted to the Grossmont Healthcare District in the last five years.

Audited Financial Statement

Accepted file types: pdf, Max. file size: 50 MB.

Attach the most recent document if needed under California minimum audit requirements.

Reviewed Financial Statement by Independent CPA

Accepted file types: pdf, Max. file size: 50 MB.

If the audited financial statements are not required for your organization, attach the most recent financial statement available. Contact GHD about the potential of including related costs in Grant Request.

IRS Tax Exemption Letter

Accepted file types: pdf, Max. file size: 50 MB.

Not required if current version was submitted to the Grossmont Healthcare District in the last five years

Board of Directors List*

Accepted file types: pdf, Max. file size: 50 MB.

Grant Application Checklist

This application is being submitted addressing one of the following "Priority Health Needs,” identified by the Community Health Needs Assessment for the San Diego East Region population. A description of how the program addresses such needs is included in the “Problem Statement/Needs Assessment” section of the application (check all of those that apply):*

Aging Concerns

Behavioral (including Mental Health and Substance Abuse Disorder)

Chronic Conditions (Heart Disease)

Chronic Conditions (Cancer)

Chronic Conditions (Stroke)

We have included the following:*

Grant Application Summary

Problem Statement/Needs Assessment

Agency Capability

Program Services and Evaluation Plan

Project Budget Form

All Budget Sources Form

We have included the following (Not required of Public Agencies)*

Articles of Incorporation *

Bylaws *

Most recent Audited Financial Statement, or:

Most recent Reviewed Financial Statement by Independent CPA

Copy of IRS Exemption Letter *

Board of Directors List

This Grant Application Checklist

* Not required if current version was submitted to the Grossmont Healthcare District in the last five years.

Please note the following:*

If applicable, we have previously submitted all required grant monitoring reports for any previously awarded Grossmont Healthcare District grant(s).

We understand that award of this grant request in no way establishes an entitlement for future financial assistance. We further understand that past funding does not guarantee funding for this grant request.

Digital Signature

Signature*

I (we) certify that all information included in this application is complete and accurate.

Digital Signature*

First Last Title

By checking the “Signature” box above and including your full name and title, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.