Hope Rises Funding Application
A Pediatrica Foundation Works Program
Applicant Information
Organization Name
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OrganizationAuthorized Representative
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First Name
Last Name
Title
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Web Address and Social Media Handles
Are you a registered not-for-profit?
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Yes - Upload proof of non-profit registration below
No - Upload a letter of support from a community sponsor below
Proof of Organization Status - Document upload
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Program Overview
Name of program or initiative
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Briefly describe your program or activity.
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Which age group(s) does your
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Early childhood (0-5)
School-aged (6-12)
Youth (13-18)
Families
Funding Request
To support the local communities we serve and promote fair distribution of funding, programming must be within a 15 mile radius of a Pediatrica practice. Please select the practice closest to your program or project.
Please Select
Pediatrica of Nocatee
Pediatrica of Philips
Pediatrica of Southside
Pediatrica of St. Johns
Pediatrica of Daytona Beach
Pediatrica of South Daytona
Pediatrica of Palm Coast
Pediatrica of Julington
Pediatrica of St. Augustine
Pediatrica of Gainesville
Pediatrica of Delray Beach
Pediatrica of Lakewood Ranch
Pediatrica of Laurel Park
Pediatrica of South Bradenton
Pediatrica of Coconut Creek
Pediatrica of Port St. Lucie
Pediatrica of Miami Lakes
Pediatrica of Westchester
How much funding are you requesting? (to a maximum of $500)
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Describe specific expenses or initiatives the funds will support
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Approximate number of youth or families who will benefit from this funding
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One organization/program is awarded funding per quarter, per practice location. If your organization is not selected this quarter, would you like your application to carry forward to the next quarter? Applications can only be carried forward once before a new application is required.
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Yes
No
Accessibility and Inclusion
Describe how your program promotes accessibility and inclusion.(e.g., free or low-cost participation, adaptive programming, financial aid, serving newcomers or youth with disabilities, etc.)
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Do you offer any support for families with financial barriers or special needs? If so, please describe.
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Impact and Alignment
How does your program/organization align with the Hope Rises objectives of youth wellness and community impact?
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What outcomes or positive changes do you expect this funding to help achieve?
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Describe how your organization ensures sustainability of your programs beyond this funding (if applicable).
Recognition and Follow Up
If your organization is selected there is a requirement to share photos, stories, or testimonials for use in Pediatrica Foundation Works promotions (website, social media, in-practice, etc.) Measures to protect the privacy of participants will be taken when required, otherwise, do you agree to provide resources and content to support this effort?
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Yes
No
Do you have social media platforms where you can post updates? (minimum of 3 posts required within a 3 month period of funding date)
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Yes
No
If you answered no to the question above, please outline potential alternative forms of recognition.
Would you be open to an in-person check presentation or feature story?
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Yes
No
Supporting Documents
Please upload any supporting documents you'd like to share, organization flyers, program outlines, etc. (optional)
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Authorization
Name of Authorized Representative
First Name
Last Name
Signature of Authorized Representative
Submit
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