2025 Hometown Health GrantNorthwest Wisconsin Region

2025 Hometown Health Grant

Northwest Wisconsin Region

PLEASE NOTE: The preferred browser to use is Microsoft Edge or Google Chrome. This form is not supported by Internet Explorer.

Mayo Clinic Health System is committed to giving back to the community. Please provide answers to required questions (as noted with an *). An up-to-date W9 is required and must be uploaded at the end of this application.

Hometown Health grants provide funds for programs or projects that have an impact in the community and align with Mayo Clinic Health System's 2025 funding priorities including:

Improve mental health
Prevent obesity and reduce chronic disease
Prevent alcohol misuse and substance abuse
Champion health equity, inclusion and diversity
Support social determinants of health efforts, including transportation, housing, food, financial or personal safety needs.

Applicants are asked to answer all the questions on the form to the fullest extent possible and attach a project budget outlining funds and expenses. You may also attach additional information about your application at the end of the form.

General Information

Name of Requesting Organization*

State the name of the program/project for which this request is being made.*

Does your proposal address a Community Health Need?*

If so, please select the PRIMARY need addressed. If no, please select N/A.

Select or enter value

Brief summary*

In a few sentences, describe the request.

Amount requested*

Other sources of funding*

List other sources of funding for the proposal.

Impact

Describe the impact the proposal will have in the community.

Who will benefit from this request?*

Select or enter value

Do any of the following descriptors apply to those served by this request?

Select or enter value

Direct Impact*

State the number (or estimate) of people directly impacted by this proposal.

Description

Please provide brief answers to the questions below. You are welcome to attach a fuller narrative at the end of the application.

What is the primary short-term outcome/goal that your program/project is aiming to achieve?*

For example: increased use of Foodshare dollars at the farmer's market

Plan*

Briefly describe the plans, including timelines for this program/project.

Collaboration*

Indicate your knowledge or understanding of other efforts in the community on this topic and the extent to which you are collaborating with those.

Evaluation*

Explain how you will measure the outcome(s) of your program/project.

Budget Information

Provide answers to the questions below and attach a full budget for the proposal (including revenue and expenses) at the end of the application.

Indicate how the funds requested from Mayo Clinic Health System will be used.*

Total Cost of the Proposal*

Indicate the total budget ($ amount) of the proposal. At the end of the application, please attach a full project/program budget. Include details of the costs of the program or project, how the requested funds will be allocated, and list other sources of income for costs of the program not covered by the funds being requested.

Recognition of funders*

Please indicate how funders will be recognized as a supporter of this proposal.

Contact Information

Please include complete contact information. Remember, the name of the organization and the address listed below must match the W9.

Tax ID number*

Indicate the Tax Identification Number of the requesting organization. This number must match the W9 or the fiscal agent for the request to whom funds will be distributed.

Name*

Title

Address*

City*

State*

Zip code*

Email*

Phone*

Website

By checking this box, I acknowledge that if funded, my organization will be required to complete an evaluation form at the end of the grant cycle and submit an acknowledgment letter of funding within 15 days of receipt of funding.

File Upload*

An up-to-date W-9 is required, please upload here. Please also add a proposal budget and any additional information you would like to share. If you have a recent project report from a previous award, please include that.

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse