Wilkes Medical Center Foundation Community Health Care Grant Application
The Community Health Care Grant Program supports health care programs and initiatives developed and delivered by community partners that align to the Wilkes County Community Health Needs Assessment (CHNA), which is conducted every three years. Priorities outlined in the assessment for 2022-2025 include: 1) Obesity and Chronic Disease, 2) Mental Health and Substance Abuse, 3) Access to Health Care and 4) Tobacco and Smoking Cessation.
Organization Information
Name of Organization
Mission Statement/Purpose
Website Address
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Primary Contact
First Name
Last Name
Title/Role
Email
example@example.com
Phone Number
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Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tax-Exempt Status
Please Select
501(c)(3)
Government Entity
Public School
Other
If you selected Other, please describe below
Other Tax-Exempt Status
Please describe your tax-exempt status
Upload your IRS determination letter
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Board Members - List
List your current Board Members and their affiliations. You may also upload a Board Roster document below.
Board Members - Upload
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Project Information
Project Name
Amount Requested
Type of Project
New
Existing
Expansion of existing
Other
Project Start Date
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Month
-
Day
Year
Project End Date
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Month
-
Day
Year
Project Description
Explain how the proposed work will support the priority goals of the Wilkes Medical Center Foundation, as aligned with the Wilkes Community Health Needs Assessment.
0/3000
Project Impact
Describe how many people will benefit from the project and in what ways.
0/1500
Key Staff
List the key staff involved with the project including their qualifications relevant to this specific request.
Project Budget - Upload file
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Upload a complete project budget, including projected revenue. List capital/one-time expenses separately from operational expenses.
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