BCH Ambassadors: Mini Grant Application

Mini Grant Application

Mini grants are awarded for non capital services or equipment that benefit patient care and/or enhances the patient experience.
Applicant Information
Mini Grant Request Name (what is this grant for?)
Amount Requested (Up to $1000)
Name

First NameLast Name
Position/Title
Department
Cost Center
Business Phone Number
Please enter a valid phone number.
BCH Email
example@example.com
Applicant Signature

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Date

MonthDayYear
Date
Required Support Information
Briefly describe the project/program/equipment.
File Upload: Attach applicable info, data, photos, etc.

Cancelof
What will this project/program/equipment accomplish and who will it benefit?
How will you recognize the BCH Ambassadors?*
What alternative solutions/funding sources have been considered?
Could this project/program/equipment be included in your operating budget?

YesNo
If yes, why has it not been funded to date?
Please itemize the cost of the project/program/equipment to be funded.
Define urgency of need(s) for this request and why: Urgent (1-2 months), Not Urgent
What is expected useful life of this request (in terms of years)?
Please include any additional information.
Director's Name*

First NameLast Name
Director's Email Address*
example@example.com
IMPORTANT: Please share with your director a copy of your submitted application by filling out the Director's Name and Email fields above. Your request will not be considered without your director's submitted review
Should be Empty:

Mini Grant Application