Community Grant Application

Community Grant Application

AllCare Health proudly works to support innovative, community-based projects that seek to improve the health of our community. If your project aligns with one of the Community Health Improvement Plan (CHP) strategies, we invite you to submit an application.

It generally takes 30 to 60-days for full grant review and distribution of funds. Submission of an application does not guarantee funding of the project by AllCare Health or its Community Advisory Councils.

AllCare Community Benefit Initiatives are not guaranteed for future funding. Requests for funding the services conducted by a staff person instead of requests for funding a salary are in line with OHA guidelines.

For more information, please reach out to the Community Engagement Team at Community.Engagement@AllCareHealth.com or by phone 541-471-4106.

Strategies for the CHPs are listed in the application. To read the full CHPs, please copy and paste these URLs:

Curry CHP: https://www.currycountychip.org/
Jackson/Josephine/So. Douglas CHP: https://jeffersonregionalhealthalliance.org/wp-content/uploads/2019/07/Full-CHIP-FINAL.pdf
Addendum to Jackson/Josephine/So. Douglas CHP: https://www.allcarehealth.com/media/3770/accco-jackson-josephine-douglas-2019-chip-addendum-pq.pdf

Smartsheet DOES NOT currently have the ability to save progress on forms before submitting them. We recommend applicants put their answers on a Word document if you need to come back to it.

You can get this document in any format you prefer free of charge. Call toll free (888) 460-0185, TTY 711, or call (888) 260-4297 for language access.

Puede obtener este documento en cualquier formato que prefiera de forma gratuita. Llame a la línea gratuita (888) 460-0185, TTY 711 o llame al (888) 260-4297 para obtener acceso a idiomas.

Organization Information

Organization Operating Name*

What name does your organization go by?

Organization or Fiscal Sponsor Legal Name

Primary Proposal Contact*

Contact Email*

Contact Phone*

Mailing Address*

City*

State*

Zip Code*

Do you have a current contracting agreement with AllCare?*

Select

Contract Details

Please describe the contracting agreement you have with AllCare.

Project Title*

Please enter the name of the project to be funded.

Project Summary Statement*

Please provide a summary statement of the project detailing (1) services/items to be funded; (2) targeted population; and (3) how the services/items improve individual and/or community health and well-being.

(Limit to 100 words and use plain language)

Estimated Number of Individuals To Be Served

Time to Implement

Select or enter value

What is the time period this grant will fund?

What type of funding are you requesting?*

Select or enter value

AMOUNT REQUESTED

Please share information about any the evidenced-based or best practices your team is using to inform this project.*

Evidence-based practice is research-based practice that has been shown effective through rigorous scientific evaluation. Best practices are generally accepted, standardized techniques, methods or processes that have proven themselves over time. Please include a link to your source if available. You may indicate "Assistance Requested"

Please check each county your project will serve.

CURRY

DOUGLAS

JACKSON

JOSEPHINE

Curry Community Health Improvement Plan*

Select one or more of the following strategies from the CHIP that your project will focus on:

Select or enter value

CHIP Priorities- Jackson/Josephine/S. Douglas*

Select one or more of the following strategies from the CHIP that your project will focus on:

Select or enter value

Intended Measurable Outcomes*

What will you be able to measure as a result of your project and how will they be measured? Examples: Number and demographics of attendees; Surveys; Continued engagement in...; Reduction in...

(Limit to 150 words and use plain language)

Leveraged Funds*

Please list the dollar amount total of leveraged funds (both pending and secured) for this grant.

Leveraged Funds Partners*

Please list the partners you have received in-kind or monetary support from.

Non-Monetary Request

Please list any in-kind/materials requests:

Select

Priority Populations and Accessibility

Which PRIORITY population(s) does your project serve?*

Please choose the PRIMARY targeted populations that will be served.

Select

LANGUAGE - ASSISTANCE REQUESTED

Would you like assistance in providing language accommodations?

Select

Project Funding and Sustainability

Budget Narrative

Please describe materials, staffing, or service details that help us understand your budget, if necessary. (Limit to 150 words and use plain language)

Sustainability Plan*

AllCare Community Benefit Initiatives typically do not fund more than 50% of staffing costs and are not guaranteed for future funding. If this proposal is for a project lasting more than one year, what plan is in place for stable funding? (Limit to 150 words and use plain language)

Supporting Documentation

The following documents must be included to complete your application.

File Upload*

Please upload the following required documents: W-9; BOARD MEMBERS list; STATEMENT OF EQUITY (hiring and providing services); and BUDGET (include cost allotments, all funding sources, and expenses for this project.)

Applicants may optionally include any Letters of Support for this grant ask.

Drag and drop files here or

Declarations and Agreements

Non-Discrimination Agreement*

In order to be considered for grant funds from AllCare, we require that you sign this Non-Discrimination Agreement. By signing this agreement, you are agreeing that your organization is an equal opportunity employer and that you do not discriminate based on race, age, color, religion, creed, sex, national origin or ancestry, marital status, veteran status, sexual orientation, gender identity, or status as a disabled individual. AllCare is committed to providing an open, diverse, and nondenominational environment. We will not support any program which requires exposure, adherence to, or conversion to any one religious doctrine in order to be a beneficiary of the program. To clarify, a direct-service program run by a faith-based organization may be eligible for funding provided the agency is an equal-opportunity employer, and the program’s beneficiaries are not encouraged or required to learn about, adhere to, or convert to that organization’s religious doctrine as a condition of receiving services from the program. “Yes” indicates agreement “No” indicates the inability to agree with this policy

Select or enter value

Conflicts of Interest*

Please state any real or perceived conflicts of interest.

Funding Disclosure*

By submitting this Grant Application on behalf of the above identified organization you acknowledge that all or a portion of the funds made available by AllCare are in whole or part subject to State and Federal laws, rules and regulations dealing with fraud, waste and abuse. Misstatements in the Application itself or misuse of Grant Funds or property acquired with Grant Funds can be subject to civil and criminal penalties.

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