2022 Community Investment Program

Mayo Clinic and Mayo Clinic Health System are committed to giving back to the community. All fund-seekers are asked to provide answers to required questions (as noted with an *). An up-to-date w9 is required. Please ensure the name and address match the organization and address in the application. Please keep your answers on this form as brief as possible (under 150 words). You may also attach additional information about your application at the end of the form. There are two main types of community investment. Sponsorship and Contribution. 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. Contributions provide funds for programs or projects that have impact in the community. Applicants are asked to attach a project budget outlining funds and expenses. Learn more about the criteria and process of the community investment program at https://communityengagement.mayoclinic.org/southeast-minnesota/ .

Briefly (under 150 words) explain the goal of the project/activity being funded by this request.

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

Please use a number. No dollar sign is necessary.

Please provide the total budget for the event/project. For contribution requests, please attach a line item budget in the upload section at the end of the application.

List other sources of funding.

If there are any Mayo Clinic employees involved in this project, please list their names below.

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

Please briefly describe outcome of that support. You may also attach additional information.

Request Details

If the request is for a grant to fund a program or activity, applicants are asked to provide brief answers (under 150 words) to the following questions. To provide more information, please upload a word or pdf file. If the request is to sponsor an event or activity, answers are not required in this section.

Briefly describe the plan to meet the goal.

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

Explain any plans to measure success of the project/activity.

List any other efforts in the community that address the stated goal and how you are collaborating with those efforts.

Impact

Please indicate the community served. Funding priority is to communities where Mayo Clinic Health System Southeast Minnesota has a presence.

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Please select the county served by this request.

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If the activity/program/event is for a General Audience, please select that option. If there is a target audience, please select the appropriate boxes that describe the population.

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Please indicate the estimated number of individuals impacted by this request (eg. program participants, expected audience, etc.). Number only.

Please indicate how Mayo Clinic as a funder will be recognized.

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Contact Information

Provide complete contact information. The address below must match the address on the w9.

This number must match the w9 or that of the fiscal agent for the request to whom funds will be distributed.

Please indicate if there is a deadline for this request.

Please add a current signed W9 with the correct name and street address (no P.O.Box), a project budget and any additional information that would be useful in evaluating the request.

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