2018GRANTAPPLICATION

This application is for organizations applyingfor

new programs or organizationsNOT fundedby DDAZF in the last three years.

Please review theGrant Application Instructionscarefully before completing this application.

Organization Name
Organization’s Executive Director / Name / Phone
Contact person/grant writer forcorrespondenceregarding thisapplication / Name / Title
Email / Phone
Program Coordinator for the proposed program / Name / Title
Email / Phone
Contact person for any oral hygiene supplies requested / Name / Title
Email / Phone
Mailing address for correspondence andnotifications regarding this grant / Addr 1
Addr 2
City, State, ZIP
Project name
Total dollar amount requested
three-year max; $50,000/year max / $ 2018 $ 2019 $ 2020
Counties or geographic area(s) to be
served by this grant
Name(s) of oral health coalitions in
which your organization participates
Provide a summary of the program
answering the following questions:
What is the program? How will the
funding be used? Who will be served
and how many?
(not to exceed 100 words)

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Application Narrative

This section is not to exceed 3 pages. Please be concise and succinct.

Type of Funding

Community-based Prevention Program
Clinical Support
Dental Sealant Program
Educational Program / Equipment
Oral Health Coalition
Treatment
Other

Program Overview

Demographic / Age / Lives Affected or Outcomes / Timeframe / Activities / OH Education Provided / Direct Services Provided

EXAMPLE:

Low income, uninsured seniors / 60+ / 140 varnish
500 OHI / 6/1/18 to 2/1/19 / RDH staff table at weekly
Phoenix senior center meetings / Yes / Screenings, varnish treatments
  1. State your organization’s mission and provide a brief history. (150 word max).
  1. Program Goal(s):

Provide the goal(s)of the program. Please provide SMART goals (Specific, Measurable, Achievable, Relevant and Time bound). This information should mirror Program Overview information above. For example:

  • Our program will provide fluoride varnish treatments to X elementary school students from March 1, 2018 to Feb. 28, 2019 by visiting X schools in X school district(s) and providing oral health education to X students during the same visits.
  • Our goal is to recruit X members to attend our monthly (quarterly) coalition meetings from March 1, 2018 to Feb. 28, 2019 by attending X outreach events, promoting the coalition through X social media posts and X email blasts.
  1. How will you evaluate and measure the program outcomes?
  1. How do you evaluate or determine uninsured status of participants, if applicable?
  1. If you are providing direct, preventive services (e.g., screenings, cleanings, fluoride varnish applications, dental sealants), please describe how you will managerestorative treatment needs identified when providing services.
  1. Describe your organization’s relationship with other community efforts, if applicable, and how your organization is coordinating with other agencies.
  1. Describe the efforts made during the development phase of this program to avoid duplication of services provided by other organizations.
  1. Include a brief timeline of activities and dates, either below or separately.
  1. List other grantmaking organizations that currently provide funding for this program, and the remaining amount needed to run the program.
  1. What opportunities are available for your organization to acknowledge a grant received from Delta Dental of Arizona Foundation? Please include possibilities, such as in-person acknowledgement (e.g., check presentation, facility tour), social media posts, traditional media, signs at events or any other possibilities.

ADDITIONAL REQUIRED INFORMATION

Please submit the following documents in order as one separate, continuous PDF file:

  • Your organization’s operating budget for the most recent fiscal year (noting your organization’s fiscal year dates). It is acceptable to use your organization’s budget format.
  • Provide a copy of the organization’s 501(c)(3) letter of determination. If the organization is a school, federally recognized Indian Tribe, or government entity, this document may not pertain.
  • A current list of the Board of Directorswith their titles and affiliations
  • Any other applicable attachments

REMINDERS:

  • Application emailed as a WORD document; remember be concise and succinct in narrative answers
  • Attachments emailed as a separate PDF document
  • Send all files to
  • Please use YOUR organization name as the file name, NOT Delta Dental; e.g. ACME 2018 Grant Application

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Budgets

Please notice we are asking you for 2 budgets:

  • The Total PROGRAM Budget -- middle column – it is the entire budget for the program
  • The Proposed DDAZF GRANT Budget – right column – explain how you will use the grant funds you are requesting in this application. If sole funding for the program is be requested, these numbers will be the same in both columns. Explain these budget expenses on the GRANTBudget Narrative page below. We compare these two budgets to understand how much of the entire project we are funding and how you are utilizing the grant funds.
  • If you are requesting funds for more than one year and the amount requested for each year is not the same, then please fill out a separate Budget pageand GRANTBudget Narrative for each year.
  • Please attempt to keep the budget to one page, if possible.

YEAR:

Expenses / Total PROGRAM BUDGET / GRANT BUDGET
  1. Salaries
/ $ / $
  1. Employee Benefits and Taxes
/ $ / $
  1. Employee Education/Training
/ $ / $
  1. Professional Fees and Contracts
/ $ / $
  1. Communications
    (phone, fax, postage)
/ $ / $
  1. Supplies not includingDDAZF Smile Bags (e.g., toothbrushes, toothpaste, or floss)
    See Application Instructions
/ $ / $
  1. Occupancy (rent, utilities, building & facilities)
/ $ / $
  1. Advertising/Printing/Publication
/ $ / $
  1. Travel/Meetings/Conferences
/ $ / $
  1. Membership Dues/Support to any affiliate Organizations
/ $ / $
  1. Evaluation
/ $ / $
  1. Non-Payroll Insurance
/ $ / $
  1. In-Kind Expense
/ $ / $
  1. Other Expenses
/ $ / $
  1. Total
/ $ / $

GRANT Budget Narrative

  • Each line of the GRANT Budget (page 3) corresponds to a line in the GRANT Budget Narrative (page 4). Both areas have a big, bold, red lines around them.
  • The amount on the GRANT Budget page is to be described in the GRANTBudget Narrative. For example: GRANTBudget on line 6, Supplies: “$500.” Line 6 on the GRANT Budget Narrative should explain that amount; i.e., “500 Happy Teeth booklets @ $1/book = $500.”
  • Provide an explanation for each expense listed in the GRANT Budget.
  • When funding for staffing or salaries (Expense Line 1) is part of the proposal, include in the GRANTBudget Narrative detail such as hours and wages per hour. (RDH for 200 hours x $25/hour).
  • Please attempt to keep the GRANT Budget Narrative to one page.

Expenses / DDAZF GRANT Budget Narrative
  1. Salaries (wages/hours)

  1. Employee Benefits and Taxes

  1. Employee Education/Training

  1. Professional Fees and Contracts

  1. Communications
    (phone, fax, postage)

  1. Supplies not includingDDAZF Smile Bags (e.g., toothbrushes, toothpaste, or floss)

  1. Occupancy (rent, utilities, building & facilities)

  1. Advertising/Printing/Publication

  1. Travel/Meetings/Conferences

  1. Membership Dues/Support to any affiliate Organizations

  1. Evaluation

  1. Non-Payroll Insurance

  1. In-Kind Expense

  1. Other Expenses

  1. TOTAL
/ N/A

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