AWHS Clinic Grant Application

The American Women’s Hospitals Service provides funding in support of programs that provide care, advancement and empowerment of women and children in underserved areas. We are devoted to fostering sustainable and innovative programs that will inspire individuals and make a difference for communities in need. Funds will be distributed on a yearly basis and typically grants are awarded between $2000 and $3500/yearly. Consideration will be given to proposals focusing on:

Sustainability
Community involvement
Community impact
How the use of funds will aid local women’s healthcare, advancement or empowerment
Strength of proposed or existing educational partnership with AWHS
Interest/potential in mentorship of students

Funds must be targeted for a specific need, not general support. Funds that help support a woman health worker's salary or specific programs that target women are especially encouraged.

The information and documentation requested below will assist AWHS in determining whether or not the organization can make a grant to your organization. Attach additional sheets in answer to questions where space is not provided.

The completed application and supporting documentation must be forwarded to AWHS by July 30th. A decision will be made within 4 weeks of the due date.

Here is the checklist of information that you will need to have available to complete this application:

[ ] Articles of incorporation or trust instrument or equivalent

[ ] Program description

[ ] Itemized budget

[ ] Most recent financial statement

Please provide the exact legal name of the organization (and any other names under which the organization has operated or operates):

Please provide the complete principal address of the organization.

Include the country code if this is outside of the U.S.

Area CodePhone Number

Website

Name of official contact for the organization.

First NameLast Name

Title

Phone Number

Country CodeArea CodePhone Number

Fax Number (optional)

Area CodePhone Number

Address (if not relevant to your country, put n/a)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Email

example@example.com

Is the organization organized as a corporation?

If no, what is the form of the organization?

Please upload a copy of the documents under which the organization was created. Examples include articles of incorporation or trust instrument, including any amendments.

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Please provide a detailed description of the principal purpose of the organization (mission):

Please provide a detailed description of the specific program the grant funds will support and how the program will support the needs, empowerment, or advancement of women. If the organization carries on different activities supported by other sources, provide a general description of those activities. (You can also upload a document. Put "see document" if you choose to upload a file.)

Program description:

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Please provide an itemized budget of the project you are proposing to receive funding. Please include line items detailing how requested funds will support salary or other empowerment of women staff. (You can also upload a document. Put "see document" if you choose to upload a file.)

Project budget:

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Please provide a description of how project activities, outcomes, and impacts will be tracked and reported.

What educational component can this project offer in conjunction with AMWA/AWHS?

Does the organization carry on propaganda or otherwise attempt to influence legislation?

If yes, please state the nature and extent of such activities:

Does the organization participate in or intervene in (including the publishing or distribution of statements) political campaigns on behalf of or in opposition to any candidate for public office?

If yes, please state the nature and extent of such activities:

Please list the full names (including middle names, if applicable) and titles of the organization's Board of Directors:

Please upload financial statements showing assets and liabilities and receipts and expenditures of the organization for the most recent year.

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Date

Name of Organization

I am authorized to sign this form on behalf of the above organization and I have examined the foregoing statements and the documents attached herto and to the best of my knowledge they are true, correct and complete.

Electronic signature:

Title: