COVID-19 Response Fund Request

Note: The Wisconsin Medical Society Foundation is dedicated to improving health and health equity in Wisconsin. As we reevaluate both our financial resources and the needs of our communities in response to the COVID-19 pandemic, racial justice and health inequities facing our state, the Foundation has suspended our regular grant application process for the fiscal year of 2021. The Foundation will instead accept funding requests to provide critical supplies and support needed to provide services to vulnerable communities and medical students during the pandemic. We hope to be able to award smaller grants beginning in 2021 and will be accepting on a rolling basis and fund as we are able.

If you have any questions about funding request, please contact Elizabeth Ringle at elizabeth.ringle@wismed.org.

Name *

First Name Last Name Suffix

Are you a Wisconsin medical student? *

A medical student at UW School of Medicine and Population Health A medical student at MCW - Milwaukee A medical student at MCW - Central Wisconsin A medical student at MCW - Green Bay A 501(c)3 organization providing direct support during the pandemic

If you are a 501(c)3 organization, what is the name of your organization?

If you are a 501(c)3 organization providing direct support during the pandemic please provide your Tax Identification Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Email *

Confirmation Email A copy of your responses will be sent to this address.

Please briefly explain how COVID-19 and the safer at home orders have impacted you directly if you are a student or your clients if you are a 501(c)3. *

How much funding are you requesting? Please note, at this time awards are limited and are dependent upon donations received. *

What will you use the funding for? *

Please verify that you are human *

Please note, if approved you are medical student and you are approved for funding you will be required to submit a W9 before funds can be disbursed.