Hometown Health Grant Application

Mayo Clinic Health System is committed to supporting health and wellness programs, projects, and events delivered through non-profit and educational organizations. We are pleased to consider requests benefiting communities where Mayo Clinic Health System – Minnesota provides services. All organizations requesting a grant must complete a Hometown Health Grant application. An up-to-date w9 is required where the name and address must match the organization and address in the application.

There are two types of grants fund-seekers are able to apply for:

1. SPONSORSHIP is typically for an event where there will be significant visibility for sponsors. Applicants are asked to answer the required questions at a minimum.

2. CONTRIBUTIONS provide funds for programs or projects that have impact in the community. Applicants are asked to answer all the questions on the form to the fullest extent possible.

All requests must align with Mayo Clinic’s mission and values. In addition, there are a number of grants that are NOT permitted under our policy, including: • Any organization that does not provide equal access or who discriminates on the basis of age, gender, race, religious affiliation, sexual preference, or disability • Endowment funds • Religious organizations requesting contributions for the sole benefit of their group or congregation, or for purposes of soliciting new members • For-profit organizations • Individuals

Please direct questions to swmnce@mayo.edu

Thank you for your interest.

Name of Requesting Organization*

Name of Program/Project/Event*

Is the request for a SPONSORSHIP or CONTRIBUTION?*

Sponsorship typically involves publicly recognizing Mayo Clinic Health System as a sponsor for an event or public-facing activity. Contribution is a request for funds for a program or organizational support. If the request is for BOTH sponsorship and contribution, choose contribution.

Select

Sponsorship Role and Recognition

Select all that apply or attach sponsorship levels at the end of the application.

Select

Date of Event

If the request if for a specific event, please list the date.

Event Location

Venue, City, State

General Information

Community*

Select the community where the activity will take place.

Select

Brief Summary*

In a few sentences, describe the request. (maximum 250 words)

Community Need

Explain the community need being addressed by this project/activity.

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.

Audience*

Which description best applies to those served by this request?

Select

Other - Audience

Provide additional information.

Previous Support

Check the box if this event/activity/organization has received money from Mayo Clinic in the past.

Previous Success

If this program or project took place in a previous year please provide a few brief successes.

Approximate Impact*

State the number (or estimate) of people directly impacted by this proposal. If this is a request for Sponsorship, please indicate expected attendance number. (We are looking for a NUMERIC RESPONSE ONLY)

Budget Information

Provide answers to the questions below.

Use of funds

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

Total Cost of the Proposal

Please list total cost/expenses for the program or project.

Recognition for funders

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

Select or enter value

List any Mayo Clinic Health System employees involved in this work.

Include the name and role in the proposed project.

Contribution Request Questions Only - Sponsorship Proceed to Contact Information Section

If you are requesting a Contribution, please provide brief answers to the questions below. You are welcome to attach a narrative at the end of the application.

How was this need identified?*

Briefly describe how the need was identified for this project or proposal.

Program or Project Description*

Briefly describe the program or project details.

Collaboration*

Please list other organizations (if any) that you are collaborating with for this proposal.

Evaluation*

Briefly describe how you will measure success of the proposal.

Contact Information

Please include complete contact information. Remember, the name of the organization and the address listed below must match the w9.

Tax Identification Number of the Requesting Organization*

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.

Contact Name*

Title

Address*

City*

State*

Zip Code*

Email*

Phone*

Website or Social Media Link

Deadline for a response (if necessary)

We will do our best to review this in a timely fashion typically within 45 days. Please let us know below if you have a deadline to be notified of the funding decision.