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)?*

Access to Healthcare (and/or healthcare utilization)Aging Related ConcernsBehavioral HealthHousingPhysical Activity and Healthy EatingSocial Determinants of HealthHealthcare Workforce Development
Which of the Social Determinants of Health are addressed by this grant (please select all that apply)?*

Economic StabilityEducation Access and QualityFood InsecurityHealthcare Access and QualityHousing affordabilityNeighborhood and Built EnvironmentResources for utilitiesPersonal SafetySocial and Community ContextTransportation barriers
Contact Person's Information:
Name*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
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.*

City of FredericksburgStaffordSpotsylvaniaCarolineKing GeorgeWestmorelandEastern OrangeSouthern Prince William
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*
Should be Empty: