Saving Ourselves GHWins Mini Grant Application

Section I. Applicant Information

Region*

Chapter*

Region/Chapter Details*

Applicant Details*

Section II: Authorizations Authorized Signatory: If awarded, who will sign off on the min-grant Memorandum of Agreement? (Provide Chapter President or Regional Director Name & Title)*

Project Contact: Who will oversee grant projects/activities? (Provide Name & Email)

Section III. Project Description In 500 words or less, describe your proposed project/event including duration, location, type of activity, project goals (ex. #attendees, educational materials distributed, vaccines administered) and how the project relates to our grant objective to reduce disparities impacting adult immunization by increasing vaccine confidence among people of color. The application should discuss how you intend to promote vaccine education and adoption.*

Section IV: Project Preparation Describe and list the preparation steps/activities needed prior to launching the proposed event/project, including outreach, budgeted expenses, facility reservation (if applicable), etc.*

Preparation Documents (Ex. Budgets, Facilities Reservation Requirements,etc)

Section V: Community Outreach Describe the community group(s) who you aim to reach, include all that apply: A. any specific neighborhood(s), zip codes, counties, etc. B. hard-to-reach, vulnerable, or disenfranchised populations (i.e. elderly, homeless, immigrant, etc.)*

Section VI. Acknowledgments

Denote that you have read and understand the below statements via checkmark (Signatures at the end represent final legal acknowledgments)

I will ensure the following are complete:

I hereby certify that to the best of my knowledge and belief that the information in this application is true and accurate:

Applicant Name (Print)*

Applicant or Authorized Signatory (Chapter President or Regional Director)

Applicant or Authorized Signatory*

Application Date*

Date

Saving Ourselves GHWins Mini-Grant Application