2025 BRA Charitable Care and Public Awareness Grant Application

2025 BRA Grant Application
Organization's Name:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Main Contact:*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Total Amount Requested: (Not to exceed $10,000)*
Do you have an ASPS member(s) participating in this project? If so please provide name(s) and ASPS ID(s). *
What percentage of your organization's current activities are specifically focused on providing breast reconstruction care/awareness?*
What type of Grant are you applying for? Please note: You cannot apply for both types of grants. If both types of grants are applied for, the applications will be disqualified.*

Charitable Care GrantPublic Awareness Grant

Charitable Care Grant
How many breast reconstruction charity care procedures has your organization supported over the last three years?*
Please provide a description of your organization's current commitment to the treatment of breast reconstruction patients, particularly those in low and moderate income households. Include historical details on how your organization has provided free or reduced price care in the past.*
Provide a detailed outline of your proposed program for which you are seeking funding, including how the program will provide breast reconstruction services.*
Upload Program Budget Here:*

IMPORTANT: Please upload all attachments as PDFs and label clearly to indicated required document your are submitting, including the the name of your organization. EXAMPE: Proposed Program budget_Name of Organization
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PROGRAM BUDGET: Provide a proposed budget totaling the amount requested broken down by patient. Please include any details on which services will be donated, or offered at reduced prices. Budgets should ONLY be for Breast Reconstruction Related Expenses and not to be combined with Breast Cancer expenses. (ex: mastectomies)

Important: Please click the link for allowable and non-allowable expenses:

https://www.thepsf.org/documents/Programs/Grants/BRAfund-Charitable-Care_Allowable-Expenses.pdf
How many women do you expect will receive care from this award?*
How many women do you expect will receive breast reconstruction surgery due to this award?*
How many women, if any, do you expect to educate about breast reconstruction due to this award?*
List the names and ASPS ID's for each Plastic Surgeon who will be involved in the charity care of patients benefiting from this grant. Include the number of breast reconstruction surgeries performed annually for the past three years for each Plastic Surgeon.
What geographic areas does your organization serve? Please describe the need within this area.*
Patient selection criteria: Describe below how your organization determines which patients are eligible for charity care and how they are selected to receive charity care. Provide details about the eligibility criteria used to select individuals to receive breast reconstruction surgery charitable care and process for verifying patient financial need. Demonstrate that the beneficiaries are from low to moderate income households, including the percentage of recipients.*
Does this proposed program target a community/population that has not yet been reached through existing initiatives; or use new or innovative approaches to reaching its target population?*
Does the program include any implementation strategies, including fundraising efforts, that will help sustain the activities after the completion of the funding period? *
Provide a description of the anticipated benefit that this award will have on your organization, breast reconstruction patients and your community.*
How will you recognize The PSF within your proposed grant program? If past awardee, how have you recognized The PSF in your promotional materials, website, etc.? *

Upload a current list of Board of Directors here.*

IMPORTANT: Please upload all attachments as PDFs and label clearly to indicated required document your are submitting, including the the name of your organization. EXAMPE: Board of Directors_Name of Organization
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Do you have an IRS Section 501(c)(3) Exemption Letter*

YesNoOther
Upload your Exemption Letter here.

IMPORTANT: Please upload all attachments as PDFs and label clearly to indicated required document your are submitting, including the the name of your organization. EXAMPE: Exemption Letter_Name of Organization
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Do you have your most recent IRS Form 990?*

YesNoOther
Upload your 990 Form here.

IMPORTANT: Please upload all attachments as PDFs and label clearly to indicated required document your are submitting, including the the name of your organization. EXAMPE: 990 Form_Name of Organization
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Upload your organization's current annual budget here.*

IMPORTANT: Please upload all attachments as PDFs and label clearly to indicated required document your are submitting, including the the name of your organization. EXAMPE: Current Annual budget_Name of Organization
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Please upload for any additional information, pictures, examples, etc. you wish to provide.

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Should be Empty:

2025 BRA Grant Application

Charitable Care Grant

Public Awareness Grant