Community Benefit GrantApplication

Thank you for your interest in the Marin General Hospital (MGH) Community Benefit program. As an independent district hospital, we are fully committed to serving the health care needs of the community. In addition to being Marin’s full-service acute care facility, we give extensive charitable resources to benefit the health and well-being of our community. Through our community benefits, we work to improve the health of our community by addressing issues and concerns that affect overall health.
Eligibility and Restrictions
MGH provides financial support to local nonprofit and public health and human service organizations that serve vulnerable communities in Marin for health related programs or issues. Only nonprofit, tax-exempt organizations and public agencies are eligible.

Community Benefit Grant Criteria:

  1. The project/organization must benefit the medically underserved residents of Marin.
  2. The project/organization must be established in the community; financial support is not available for start-ups.
  3. The project/organization must be directly related to access to healthcare and supportive services, e.g. primary and specialty care, enrollment in available coverage programs, behavioral health services, immunizations, services that support appropriate outpatient and community-based services.
  4. No capital (bricks and mortar) projects.
  5. The project addresses access to care.

Community Benefit Grants are generally NOT awarded for:

  • Arts programs
  • Cultural events
  • Schools/education
  • Athletic programs, such as sports teams or leagues
  • Fundraising activities
  • Annual fund drives
  • Building or capital campaigns
  • Individuals
  • Religious organizations (religious purposes or exclusive benefit of their members)
  • Political campaigns

Applications must include program/project objectives and evaluation metrics for each objective. The goal of the evaluation process is to answer the questions: how much did you do, how well did you do it and what difference did it make? Examples of evaluation metrics include: the number served, the change in the number served compared to a previous period, self-reported change in health knowledge or behaviors, change in health status, change in utilization of services, benefits to the participants made possible by the program/project, etc.

Submissions/Questions
For questions or to submit your application, please contact Community Relations at .

2018Grant Application

We must receive a completed application for consideration no later than 12 noon on Friday, August 25, 2017. Your total organization budget for the year and the total budget for this project must also be submitted with the application.
Applicant Information

Name:

Phone: Fax:

Email:

Relationship/Position in Organization:

Organization Information

Name:

Address:

City: State:Zip:

Website:

Tax Status: Tax ID#:

Brief Organization Description (including mission, goals and communities served):

Application/Project Request Information

Project Title:

Start Date: End Date:

Summary:

Objectives and Evaluation Metric(s) for each Objective

Objective / Evaluation Metric(s)

Total Project Budget (must be submitted with application):

Amount of funding you are requesting from Marin General Hospital (MGH):

What line items would MGH funding go towards and in what time frame would it be used:

Other sources of funding (including already secured and pending):

Populations served (please select all that apply):

Insurance GenderAge GroupRace/Ethnicity
Insured Male <18 African American
Uninsured Female 18-40 Asian

Both 40-65 Caucasian
65+ Hispanic or Latino

Native American

Pacific Islander
Other: ______

Other Populations
Homeless Mentally Ill Disabled
Low Income Non-English Speaking Veterans
Number of people expected to reach/serve:

Payor mix of clients and patients:

Organization / Project
% Charity Care
% Self pay, income based discount
% Medi-Cal
% Medicare
% Commercial insurance

Other partners involved in the project and their role:

Evaluation

How will outcomes be measured?

Federally Qualified Health Center Applicants
Please see supplemental instructions and data requested.

If your grant request is approved, a final report will be due by January 31, 2019.

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