Community Small Grants Program Application

LifeBridge Health, Inc. (“LifeBridge”) offers small grants to associations in communities contiguous to LifeBridge institutions for a maximum of $1,000 per year to help eligible organizations offer events that benefit residents.

EVENTS MUST BE FREE AND AVAILABLE TO ALL RESIDENTS AND OTHER
PARTICIPANTS.

Who may apply: A nonsectarian, nongovernmental association in a community nearby a LifeBridge institution, with at least ten members or affiliates, and a bank account in its name. Please include a list of members or affiliates with this application. Governmental organizations and events are not eligible.

What will be funded?: Priority will be given to small community associations for events addressing health and safety, neighborhood beautification and greening, sports and recreation and youth programming.

What will not be funded?: Grants are not available for routine operations or equipment, or to offset any ongoing operational costs of the sponsoring organization.

Award Amounts: Eligible applicants may receive up to $1,000, contingent upon availability of funding.

Funds awarded must be used within 2 years of award date or money must be returned.

Application and Award Process:
• Applicants must complete all parts of the application form.
• Late or incomplete applications will not be reviewed.
• All applications will be scored by a review committee and the committee reserves the right to request additional information. The review committee makes recommendations to the LifeBridge Department of Government Relations and Community Development. All decisions are final and are not subject to any appeal process.

Please type your information on the below application.

For an electronic application help, additional information, or assistance in determining eligibility, please contact Sharon Henderson at shahende@lifebridgehealth.org or 410-469-5640.

Organization Name:*

Applicant Name:*

First NameLast Name

Applicant Title:*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant Phone Number:*

Please enter a valid phone number.

Applicant Email:*

example@example.com

Organizational Status (select all that apply):*

Non-ProfitFor-ProfitNew OrganizationExisting Organization

Closest LifeBridge Health Institution:*

Sinai/LevindaleNorthwest HospitalCarroll Hospital

How many years has the organization or group been in existence

Federal ID Number (if applicable)

Insurance Company and Policy Number*

Attach Policy Summary Sheet*

Bank Account Name and Number*

Attach a voided check or deposit slip*

List of members or affiliates *

If Contact Person is different than the Applicant Person above, fill out the Contact Name and below sections

First NameLast Name

Contact Person Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Person Phone Number

Please enter a valid phone number.

Contact Person Email

example@example.com

Project Title/Description: Please include location and purpose of project and how it will be implemented. *

Target population and total number to be served by the project:*

Check here if this event is free and open to all residents and participants

How your organization will obtain participation: *

Proposed date, start & end times, and location:*

Total amount of grant $ being requested:*

Total cost $ of project:*

Have you received, or will you be applying for, any other funding to assist with this project?*

YesNo

If yes to last question, from where?

Please list all expenses for this project with their cost and description/use. REMINDER: Routine operating expenses are not permitted

Any additional supporting materials (i.e. pictures, flyers)

I understand and agree that LifeBridge Health assumes no responsibility or liability for injuries to persons or property that result from or relate to use of the funds received by me from LifeBridge Health pursuant to this grant. I agree to indemnify and hold harmless LifeBridge Health and its officers and employees from any claims,
damages, judgments, or losses arising from any injuries to persons or property arising in connection with or related in any way to use of the funds received by me from LifeBridge Health pursuant to this grant. I further agree that funds will be spent only as specified in the award letter. Any changes must be approved in advance of
expenditure.

All information included in this Community Small Grants Program Application is accurate to the best of my knowledge.

Signature of Applicant:

Print Name

Signature of Project Coordinator (if different from Applicant): :

Print Name