FOUNDATION GRANT REQUEST FORM

FOUNDATION GRANT REQUEST FORM
All grant requests, whether under or over $1,000, now use the same application form. All form fields are required. Use “NA” for sections that do not apply.

Requests over $1,000 require additional approval from the SMMC Leadership Team (SLT), which the Foundation will help coordinate.

Your supervisor must be informed of this request before you submit the form. Grant approval must be secured prior to making any purchases—after-the-fact requests are not guaranteed to be reimbursed. Do not proceed with any transactions until you receive written confirmation from the Foundation. Please allow 7–10 business days for review; some requests may take longer.

If your grant request is for an Annual Recognition Week event, the amount awarded is $25 per staff member in your department. Annual Recognition Week events are nationally/globally recognized events that celebrate a specific healthcare department or role such as Nurses Week, Radiologic Technology Week, etc. This fund is not meant for regular team celebrations (e.g., life events such as birthdays, work anniversaries, baby showers; staff retreats; team building activities, etc.).

For reimbursement of an approved grant, submit a Reimbursement Form with receipt(s) attached.

Questions? You can reach us Monday–Friday, 9 AM–4 PM at info@smchf.org or (650) 573-2655.
I have verified that the requested project or items are not directly covered by the hospital or county. My supervisor, listed below, has pre-approved my submission.*

Yes
Supervisor*

First NameLast Name
1. TODAY'S DATE*

MonthDayYear
2. REQUESTER*
3. DEPARTMENT NAME*
4. DEPARTMENT ORG #*
5. PROJECT NAME*
6. ANTICIPATED PROJECT START DATE*

MonthDayYear
Date
7. TOTAL AMOUNT OF GRANT REQUESTED*
Please allot for all associated fees (e.g., service charge, tax, shipping, etc.)
8. Classification (Check all that apply)*

Patient careMedical equipmentStaff well-being/engagementOther
9. Alignment (Check all that apply)*

MissionStrategicOperational
GRANT DETAILS
10. Describe the project for which you are seeking support and how it aligns with SMMC’s mission and priorities.*
11. Describe your project's impact, including the beneficiaries and estimated number of patients or staff affected. How will you measure its success?*
12. Is your request associated with a staff event or celebration? Please note that additional approvals may be required.*

YesNo
PURCHASING
If you are requesting supplies, you have three options:
- Buy it yourself and submit a reimbursement request with receipts; or
- Have the vendor invoice us - we'll pay them directly; or
- Ask the Foundation to order it online (e.g., Amazon). You will need to provide direct links and complete details (e.g., quantity, color). The Foundation cannot research items for you.
For Food
- The Foundation will not place restaurant or delivery app orders (e.g., DoorDash).
- You can:
  - Send us a catering invoice and we'll pay the vendor directly; or
  - Buy the food yourself and submit a reimbursement request with receipts.
13. To request Foundation assistance with purchasing supplies (e.g., via Amazon), provide full details below—including direct links, quantity, color, and any options. Your total must include all costs (tax, shipping, fees) and be within your approved grant amount, so please double-check quantities.*
14. DATE FUNDING OR SUPPLIES NEEDED BY*

MonthDayYear
Date
PAYMENTS / TRANSACTIONS
15. How would you like to receive the approved funds?*

I will handle payment and submit a reimbursement request with receipts to the Foundation via the provided link.I would like the Foundation to pay the vendor directly. I will include the vendor's information below. **We will let you know if we require a copy of their current W-9.
Use "NA" if fields below do not apply
Company*
Point of contact*
Email*
Phone number*
16. Please upload back-up documentation, if appropriate.

i.e., Estimate, etc.
Cancelof
OFFICE USE ONLY
Accounting

Approved ByDate
CFO

Approved ByDate
FP&A

Approved ByDate
SLT

Approved ByDate
SMCHF

Approved ByDate
Grant #
Fund
Payee
Amount
Check #
Notes
www.smchf.org

222 West 39th Avenue San Mateo, CA 94403 (650) 573-2655 office (650) 573-3447 fax
Should be Empty:

FOUNDATION GRANT REQUEST FORM

GRANT DETAILS

PURCHASING

PAYMENTS / TRANSACTIONS

OFFICE USE ONLY