Concept Paper Application

Joe and Mary Wilson Community Benefit Fund of Mary Washington Hospital and Stafford Hospital Community Benefit Fund

Concept Paper Application

Organization Name

Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Title of Program

Which of the Responsive Grant Making objectives will the program specifically address (please select all that apply)?

Which of the Social Determinants of Health are addressed by this grant (please select all that apply)?

Contact Person's Information:

Name

First NameLast Name

Title

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Fax Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Organization's founding date and mission statement

Organization's fiscal year (beginning and end dates)

Total program cost and the dollar amount requested from the Community Benefit Fund.

What is the problem this program will address?

0/175

Describe the target population to be served including the approximate number of people to be served.

0/175

Name the geographical area(s) to be served.

Describe the results you are committed to achieving.

0/175

How do you intend to accomplish these results?

0/175

How will the requested funds be spent?

0/175

Describe the partnering organizations and community support for the program.

0/175

Signature of the Senior-Ranking Executive.

Please verify that you are human