Community Impact Grant Application for Corning, NY & Steuben County, NY

Community Impact Grant Application for Corning, NY & Steuben County, NY
The American Heart Association wishes to extend an opportunity for making a difference in Corning, NY and the surrounding area of Steuben County with gratitude and thanks to the Estate of Mary Vohar Lilley. Proposals ranging from $500 up to $10,000 will be accepted focusing on:

Improving Nutrition Security
Ending E-Cigarette and Tobacco Use
Controlling Blood Pressure
Community Response (CPR)

Priority will be given to projects directly benefiting the City of Corning; all funds must be utilized within Steuben County, NY. 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 Name Last Name
Project Leader Title/Role *
Organization(s) Name: *
Project Title: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
How did you hear about this grant?
Email *
example@example.com
Cell Phone Number *
Please enter a valid phone number.
Contact Name 1:

First Name Last Name
ADDITIONAL CONTACTS

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

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

First Name Last 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

City State / Province

Postal / Zip Code
What is the proposed outreach location(s) for this project?
What geographic area will this project directly benefit: (PLEASE SELECT ONE OR MORE OPTIONS) *

Corning, NY Steuben County, NY Another community/region within Steuben County, NY - not county wide
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*
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 *

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Proposed Program Budget *

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