San Juan Fund Grant Application
Montrose Regional Health Foundation Grant applications will be reviewed on a rotating basis with no specific deadline.
Contact Information
Full Legal Organization Name
*
Organization Website
Organization President / Executive Director/ Director
First Name
Last Name
Title
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person Filling Out Application
*
First Name
Last Name
Title
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-Mail Address
*
example@example.com
Are you a Montrose Regional Health Employee?
*
Yes
No
Have you attended a MRH Foundation event in the past 2 years?
*
Yes
No
If yes, what event did you attend?
Organization Information
501(c)(3)?
*
Yes
No
Year Established
Total Organization Budget
Total # of Board Members
Total # of Staff
Total # of Volunteers
Organizational Mission Statements
*
Brief Description of Organization
*
Population Served
*
Proposal Request
Program / Project Name
*
Type of Request
*
Please Select
Capacity Building
Capital Campaign
Event
General Operating
Multi-Year Project
Program Support
Scholarship
Start Up
What is the project? What are the goals of this project?
*
How has your organization worked to address healthcare in the region?
*
How will this project fulfill a specific healthcare need in the region?
*
How will this project align with your mission as well as the mission of the Montrose Regional Health Foundation?
*
What will a successful project look like?
*
Are there any partnerships?
*
Budget
Program/ Budget Budget
*
Requested Amount
*
Percent of Total Budget
*
Other Funding Sources?
*
Describe the budget above, including how the project will move forward if only partial amounts are awarded from the San Juan Fund or other sources. If San Juan Fund is your only request, please tell us why.
*
Project Timeline: Start Date
*
-
Month
-
Day
Year
Date
End Date
*
-
Month
-
Day
Year
Date
Multi-Year?
*
Yes
No
Geographic Area Served
*
Have you received prior grants from the Montrose Regional Health Foundation?:
Amount (1)
Date (1)
-
Month
-
Day
Year
Date
Amount (2)
Date (2)
-
Month
-
Day
Year
Date
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