Foundation Grant Information

Foundation Grant Information Request Form

The Wisconsin Medical Society Foundation grants funds to qualified nonprofit organizations endorsed by Wisconsin physicians. Funds are to be used toward the Foundation's mission to improve health by increasing health equity and access in Wisconsin.
Nonprofit Organization Information
Organization of applicant*
Organization tax ID number*
Name of the individual completing this form*

First NameLast NameSuffix
Preferred Name
How do you prefer to be address, for example Kate versus Kathryn or Dr. Wilson versus Sandra
Pronouns
Title/Role of individual completing this form
Email*

Confirmation EmailA copy of your responses will be sent to this address.
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please briefly describe your organization's purpose and mission.*
If awarded funds from the Foundation, would any funds be used for the following purposes?*

The use and payment for services of a fiscal agentEndowment fundsReligious organizations for religious purposesFund raising activities or events (i.e. annual fund drives; benefit tickets)Umbrella funding organizations that intend to distribute funds at their own discretionPolitical lobbying or legislative activitiesPayment directly to individualsCapital expenditures (i.e. building repairs; etc.)None of the above
The Foundation does not grant funds for this purpose. If you have questions, please contact Elizabeth Ringle at elizabeth.ringle@wismed.org. We wish you all the best with your endeavors.
Funds granted by the Foundation are to be used to further our mission to improve health by increasing health equity and access in Wisconsin. Foundation grants are typically for $5000 with rare exceptions. If awarded, in what way would your organization use these funds toward that mission?*
Please list the Wisconsin counties served by your organization.*
Please list the cities/communities impacted by your organization.*
What is the anticipated number of individuals directly impacted by your organization?
(Please include all direct recipients of service.)
Who is the primary audience of your organization?*

Birth through age fiveSchool-age childrenWorking adultsSeniorsCommunity-at-large/PublicPhysiciansMedical studentsOther
Additional Documents

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By submitting this application you are acknowledging all information provided is complete and accurate to the best of your knowledge. You acknowledge you hereby give the Wisconsin Medical Society Foundation permission to share this information for the purpose of public relations and reporting. Falsification of information may result in the termination of any grant awarded. All application materials become the property of the Wisconsin Medical Society Foundation.
Please verify that you are human*
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Foundation Grant Information Request Form

Nonprofit Organization Information

Additional Documents