Bridge of Life Partner Interest Form

Organization Name

Organization Website

City

Country

Applicant Name

First NameLast Name

Profession

Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Describe your organization, including mission and recent accomplishments.

What areas does your organization work in? Check all that apply.

Describe the current health services your organization provides.

Who does your organization serve? Describe the patient or population demographics.

Describe any specific CKD treatment and/or prevention services offered.

How does your organization collect data and measure impact?

Does your organization have experience implementing health programs similar to the ones offered by Bridge of Life?

If yes, please explain.

Please provide an overview of your current staffing size and a breakdown of their roles.

Describe the specific community or region where the proposed partnership will take place.

What are the primary health challenges in this community (specifically regarding non-communicable diseases like diabetes, hypertension, and kidney disease)?

What are the main barriers to healthcare access for this population (e.g., financial, geographic, lack of specialists, etc.)?

Describe the existing local infrastructure to support healthcare initiatives (e.g., local clinics, hospitals, reliable access to water/electricity, etc.).

What areas are you interested in partnering with Bridge of Life on? Please select all that apply.

Other

Please select the CKD Prevention & Early Detection project(s) you would be interested with partnering with Bridge of Life on.

Other

Please select the Clinical Training & Health System Strengthening project(s) you would be interested with partnering with Bridge of Life on.

Other

Please select the Treatment Infrastructure & Direct Clinical Services project(s) you would be interested with partnering with Bridge of Life on.

Other

Please describe the specific project or initiative you are seeking support for.

Why is this project a priority?

What outcomes are you hoping to achieve?

How does this align with your organization’s priorities?

It is important that our partners share the investment in projects alongside Bridge of Life. What will your organization contribute to ensure the success and sustainability of this project? Select all that apply.

How do you plan to sustain this program financially and/or operationally after the initial partnership with Bridge of Life?

What are your organization's existing funding sources for this or similar initiatives?

Is there any local or national government involvement in your programs?

Please describe any existing community partnerships that will support the success and longevity of this initiative.

What does success look like in 3 to 5 years if this partnership is successful?

Please provide any additional information that would be helpful for us to know.

Bridge of Life (BOL) evaluates potential partners based on their ability to support sustainable, long-term systems of care. If selected for a partnership, organizations are expected to commit to the following:
• Local Collaboration: Provide a dedicated project liaison, secure necessary venues, and manage local logistics and community/patient outreach.
• Clinical Commitment: Ensure local clinical staff have the time to participate in BOL training and commit to integrating best practices and follow-up care pathways into daily operations.
• Data & Evaluation: Collaborate on shared program goals and provide timely data and reporting to track patient outcomes and measure impact.
• Shared Storytelling: Adhere to agreed-upon branding guidelines and assist in gathering testimonials and photos (with proper consent) to highlight the impact of the program.
• Sustainability: Demonstrate a clear plan for taking local ownership and sustaining the programs independently over time.

Bridge of Life Partner Interest Form

Organization Information

Community Information

Partnership

Sustainability

Additional Information

Partnership Considerations and Requirements