Is your organization a 501(c)(3) nonprofit organization operating as a general acute care hospital licensed by the State of California or a 501(c)(3) nonprofit community-based organization addressing specified health priorities in Orange County?
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Yes
No
Grant Applying for:
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Nonprofit Hospital Grant
Community Based Organization Grant
Based on the Foundation’s mission, funding priorities, geographic area of support and current granting, do you believe that your organization is a strong candidate for consideration?
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Yes
No
Organization and Contact Information
Organization Name:
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Address:
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Street Address
Street Address Line 2
City
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Alabama
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California
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District of Columbia
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Montana
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North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Postal Code
Phone Number:
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Format: (000) 000-0000.
Extension:
Website:
Tax ID:
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Please provide your social media handles, if any:
Please provide your organization’s Mission Statement (100 word max):
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0/100
Applicant Contact Information
Prefix (select one):
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Please Select
Doctor
Dr.
Justice
Miss
Mr.
Mrs.
Ms.
Professor
Reverend
Rabbi
The Honorable
Name:
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First Name
Last Name
Title:
Email:
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Phone Number:
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Format: (000) 000-0000.
Extension:
Executive Director/CEO Contact Information
If different than information above
Prefix (select one):
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Please Select
Doctor
Dr.
Justice
Miss
Mr.
Mrs.
Ms.
Professor
Reverend
Rabbi
The Honorable
Name:
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First Name
Last Name
Title:
Email:
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Office Phone:
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Format: (000) 000-0000.
Extension:
Request Details
Amount Requested:
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Please keep in mind, median grants are $15,000 for Community Based Organizations and $100,000 for Hospitals and CBO-Hospital collaborations. If you have a larger ask, please note that our ranges do vary.
Geographical Area Served for this application (Select all that apply):
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Tustin
Santa Ana
Anaheim
Orange
Primary HFOC Objective Area (Select one):
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Address community health priorities and delivery system gaps
Remove barriers to healthcare
Provide culturally relevant information and services to communities
Empower parents and caregivers with information and support to assure family health
Project or Program name (20 word max):
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0/20
Number of persons served annually by the program or project:
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Gender Groups Served:
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Rows
Estimate in percentages the gender groups that will be affected (Total must add up to 100).
Female:
Male:
Non-Binary:
Age Groups Served:
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Rows
Estimate in percentages the age groups that will be affected (Total must add up to 100).
Infants (0-5):
Children (6-13):
Young Adults (14-18):
Adults (19-64):
Seniors (65+):
Racial/Ethnic Groups Served:
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Rows
Estimate in percentages the race and ethnic groups that will be affected (Total must add up to 100).
American Indian and Alaskan Native:
Asian American or Pacific Islander:
Black or African American:
White:
Hispanic/Latino:
Middle Eastern or North African:
Multi-racial:
Another race, not listed:
Description of organization (200 word max):
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Please provide a description of your organization including the history and purpose of your organization.
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Summary of the proposed program(s) or project (300 word max):
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Please provide an overview of your proposed program(s) or project. Please describe the issue or problem your program/project aims to solve, the target population(s) and how your program/project will do that.
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Collaborative partners (150 word max):
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Describe the existing, future, or non-traditional partners that are already in place or will be involved to support the implementation of your program/project goals. (If no partners are needed, please explain.)
0/150
Evaluation plan (200 word max):
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Please provide your evaluation plan for how you will assess the success of your efforts. Please include what metrics will be tracked, and the outcomes of those metrics.
0/200
Other sources of funding (200 word max):
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List other potential funding sources for the project/program, ex.: Government, Corporations, Foundations, Individuals. Also indicate amount sought from each.
0/200
Ongoing funding (150 word max):
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How will the continuation of this project be financed after initial funding expired?
0/150
Required Documents
All uploaded documents must be in PDF format not to exceed 25MB. Please resize and submit if necessary https://pdfresizer.com/resize
Most recent Financial Statements or 990 form:
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501(c)(3) Determination Letter:
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Project Budget:
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Organization Budget:
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Board of Directors:
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