FOUNDATION GRANT REQUEST FORM

FOUNDATION GRANT REQUEST FORM
Grant Request Instructions
- This application is for a grant request to the Foundation.
  All fields are required. Enter “NA” if a section does not apply.
- Requests over $1,000 require approval from the SMMC Leadership Team (SLT). The Foundation will coordinate this.
- Before submitting:
  1. Inform your supervisor.
  2. Submit your application before making any purchases.
- Do not spend money without grant approval from the Foundation.
  Reimbursement is not guaranteed for purchases made before approval.
- Timeline:
  1. Review takes 7–10 business days (may take longer).
  2. Submit at least 2 weeks before your project start date
Annual Recognition Week Requests
- Applies only to recognized healthcare events (e.g., Nurses Week).
- Not allowed for regular team celebrations such as birthdays, anniversaries, baby showers, retreats, team-building events.
- Funding (if approved) = $25 per staff member in your department.
Reimbursement (after approval)
- Submit a Reimbursement Form with receipts attached.
Questions?

Email or Teams Dana Floro c_dfloro@smcgov.org
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.
Your Supervisor's Name

First NameLast Name
1. TODAY'S DATE

MonthDayYear
2. YOUR NAME (REQUESTER)

First NameLast Name
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)

Other
9. Alignment (Check all that apply)
GRANT DETAILS
10. Describe the project you are seeking support for 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 an annual recognition healthcare event? (The Foundation will let you know if additional approvls are required.)
12a. What is the name of your healthcare event?
12b. How many department staff members are included in your healthcare event?
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. If you would like the Foundation to purchase the supplies needed (e.g., Amazon), provide full details below with direct links, quantity, color, and specific options needed. 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?
Vendor (Company name)
Point of contact
Email
Phone number
16. Please upload back-up documentation, if appropriate.

i.e., Estimate, etc.
Cancelof
FOUNDATION 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

FOUNDATION USE ONLY