Grant Application Guidelines

Cheyenne Regional Medical Center Foundation created this Grant Application Form to provide those requesting grants and the Foundation with basic information needed to make informed grant decisions. Please contact the Foundation with any questions – 307-432-2667.

Applicants should be available to appear before the Foundation’s Endowment Committee to answer questions and provide additional information if asked to do so. Applicants are advised that the Foundation’s grant making policy gives priority to the purchase of equipment and the funding of programs which will be used by or directly benefit the operation of the Hospital.

Please be advised that funds awarded must be used for successful grant requests within one year of the date of the award.

CHECKLIST

GRANT APPLICATION FORM-Please complete the attached template

NARRATIVE-Please thoroughly respond to the two grant description questions on page 3. If you wish you may include additional information. In providing information in support of your request please include the following:

  • Background – discuss the premise and need for the grant
  • Goals – what does your department want to accomplish with the funds requested
  • Evaluation – describe the approach which will beused to evaluate and measuretheimpact ofthe funds requested
  • Collaboration – describe any interactions with other departments or organizations

FINANCIAL ATTACHMENTS

  • Please submit proposal(s) or estimate(s) from vendors or service providers detailing the costs involved with your grant request. If your proposal involves multiple expenditures, please provide an itemized budget. Also identify which of the vendors has been approved by CRMC as an equipment or service provider

SIGNATURES

  • Please be sure your grant request is signed by the individual/contact person submitting the request AND by the appropriate Hospital VP or Department Manager

PLEASE SUBMIT A HARD COPY OF THE GRANT APPLICATION

  • ToWendy Fanning, Director of Annual Giving and Grants at the Foundation Office and an electronic copy

GRANT APPLICATION FORM

Department Name:

Department Location:

Phone: Fax: Dept #

Grant Request Contact Name& Title:

Phone: Email:

Grant Request Information

Type of Grant Requested (select one):

Equipment

Program Support

Education

Other

Amount of Request: $

Describe how the grant will be used by your department:

Population and/or Area to be served (specific to this proposal):

Financial Information

Has this request been submitted to Cheyenne Regional’s Capital Budget? If so, please specify the outcome.

Is this request also part of your Department’s Current Fiscal Year Budget?

If this request is not part of either budget, is it eligible to be submitted as part of a future budget request?

What other sources of funding, if any, have you pursued for this request

(for example, local non-profits, other Foundations, etc.)?

If you have pursued other sources of funding, what have been the outcomes of those grant requests?

By signing below, I certify that the information contained in this application is true and correct to the best of my knowledge.

GRANT REQUEST CONTACT:

SignatureDate

Please print Name/Title

GRANT REQUEST APPROVAL:

VP/Manager SignatureDate

Please print Name/Title

Cheyenne Regional Foundation Grant Application
Approved February 2013, Revised August 2014 / Page 1 of 4