2027 HFOC Grant Application

2027 Healthcare Foundation for Orange County Grant Application
Required Documents

All uploaded documents must be in PDF format not to exceed 2 MB

*Most recent Financial Statements or 990 Form

*501(c)(3) Determination Letter

*Project Budget (please use this template and save as: organizationname.2027 Project Budget)

*Organization Budget

*Board of Directors

*Certificates of Insurance (i.e. proof of Worker’s Compensation, General Liability, Professional Liability, etc.)
Organization and Contact Information
Organization Name:
Address:

Street Address

Street Address Line 2

CityState

Postal Code
Phone Number:
Format: (000) 000-0000.
Extension:
Website:
Tax ID:
Please provide your social media handles, if any:
Please provide your organization’s Mission Statement:

0/100
Please provide a description of your organization including the history and purpose of your organization:

0/200
Applicant Contact Information
Prefix (select one):
Name:

First NameLast Name
Title:
Email:
Phone Number:
Format: (000) 000-0000.
Extension:
Executive Director/CEO Contact Information

If different than information above
Prefix (select one):
Name:

First NameLast Name
Title:
Email:
Office Phone:
Format: (000) 000-0000.
Extension:

Fiscal Sponsor Information
Does your application include a fiscal sponsor? If yes, please see the questions at the bottom of this application. Grant application must be completed by the fiscal sponsor.

Rows	Estimate in percentages the gender groups that will be affected (Total must add up to 100).
Female:
Male:
Non-Binary:

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+):

Rows	Estimate in percentages the race and ethnic groups that will be affected (Total must add up to 100).
Hispanic or Latino:
Not Hispanic or Latino:
Unknown or Declined to State:

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:
Black or African American:
Native American or other Pacific Islander:
Middle Eastern or North African:
Multi-racial:
White:
Unknownor Declined to State:
Another race, not listed:

2027 Healthcare Foundation for Orange County Grant Application