Mary Vohar Lilley Community Impact Grant Application

Mary Vohar Lilley Community Impact Grant Application
The American Heart Association wishes to extend an opportunity for making a difference in Corning, NY and the surrounding communities through Community Impact Grants made possible by the Estate of Mary Vohar Lilley. Proposals ranging from $500 up to $10,000 will be accepted focusing on:

1. Controlling Blood Pressure

2. Improving Nutrition Security

3. Ending E-Cigarette and Tobacco Use

4. Community Readiness

Priority will be given to projects directly benefiting the City of Corning; all funds must be utilized within Steuben County, Allegany County, Chemung County, Schuyler County, Yates County, or Livingston County. We are looking for innovative projects that address social determinants of health and work to increase access to blood pressure screenings and education, increase the consumption of healthy foods, decrease tobacco, vaping, and e-cigarette use and improve cardiovascular health outcomes in underserved populations.
Project Leader Name*

First NameLast Name
Project Leader Title/Role*
Organization(s) Name:*
Project Title:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about this grant?
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
ADDITIONAL CONTACTS

ADDITIONAL CONTACTS THAT SHOULD BE INCLUDED ON COMMUNICATIONS RELATED TO THE DETAILS AND EXECUTION OF THIS GRANT PROGRAM.
Contact Name 1:

First NameLast Name
Contact Title/Role 1:
Contact Email 1:
example@example.com
Contact Name 2:

First NameLast Name
Contact Title/Role 2:
Contact Email 2:
example@example.com
FINANCIAL INFORMATION

(Please note, award checks will be made payable exactly as indicated below and will not be reissued for incorrect information provided.)
Federal Tax ID of Organization:
** (Do not list any individual Social Security number) **
Make Check Payable To:
Send to the Care of:
Mailing Address for Check:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Project/Program Description: Provide an overview of the proposed project/program to be supported through this grant. Include the project/program’s intended purpose, activities, and alignment with areas of interest
Corning, NYSteuben County, NYAnother community/region within Steuben County, NY - not county wideAllegany County, NYChemung County, NYSchuyler County, NYYates County, NYLivingston County, NY
What is the target population for this project?*
How many people are estimated to be impacted by this project directly? blanks* . How many people are estimated to be impacted by this project indirectly? blank*
AMOUNT REQUESTED FOR THIS SPECIFIC PROJECT (Dollar amount from $500.00 - $10,000.00) blanks* .
CLEAR STATEMENT OF NEED FOR THIS SPECIFIC PROJECT*
WHAT OTHER ORGANIZATION(S), IF ANY, ARE YOU WORKING ON THIS PROJECT WITH?*
UP TO 200 WORDS

HOW DOES THE DATA SHOW A NEED FOR THIS PROJECT IN YOUR COMMUNITY?*
UP TO 200 WORDS
PROGRAM OBJECTIVES & METHODOLOGY*
UP TO 300 WORDS
PROGRAM OUTCOMES*
UP TO 300 WORDS
PAST SUCCESSES*
UP TO 100 WORDS
PROGRAM EVALUATION*
UP TO 250 WORDS
COMMUNITY IMPACT AND SUSTAINABILITY*
UP TO 250 WORDS
SUPPLEMENTAL ATTACHMENTS FOR APPLICATION*
File Upload of Signed W9 in PDF Format*

Cancelof
Proposed Program Budget*

Cancelof
Supplemental Document*

Cancelof
ELECTRONIC SIGNATURE*

Clear
Should be Empty: