Health Fund Online Grant Request System Sample Form

Grants for Healthy Kansans

Sample Application Form

The following form indicates the kinds of information we require to be able to evaluate requests for grant funding. In some cases we may require either more or less information than is asked for in this general application form. If you have received authorization to apply, the program officer you have been in communication with will provide any additional instructions you may need.

When filling out the online form, all information will be visible on screen as one long document. The form is designed to be simple and straightforward. Therefore, only one section at a time will be active for editing. When you save changes in a section, the form will automatically activate the next section for you. You can follow this process straight through the form, or you can edit sections in any order you wish by clicking a link under the section heading.

In the form below, the second section, "Applicant Organization Information" is active for editing and therefore highlighted in yellow. All inactive sections are highlighted in teal. This sample form is not "live" so it will not respond to button clicks as the real form would.

Using the authorization number provided by your program officer, and the password you select on first login, you can return to continue your application over as many sessions as you wish. If you have questions about responses to the application form, please contact your program officer. If you are experiencing technical problems with using the online form, contact Jeff Gamber at 620-662-8586 or email through our contact page.

Important notice about our grant application/proposal rules

The Health Fund has specific rules regarding grant funding and application procedures. To save yourself time and unnecessary work, please read and be familiar with the following rules:

Kansas, USA only - the Health Fund only funds projects to benefit the health of Kansas residents. The Health Fund does not fund projects in other U.S. states or foreign nations.
No uninvited/unauthorized proposals or applications - the Health Fund will automatically reject without consideration any proposals or applications which were not authorized or invited in advance by a Health Fund program officer.
Strategic focus areas - the Health Fund has focused its efforts on a select group of funding areas to achieve greater impact with limited resources. Our grants are limited to projects addressing one or more of those areas. Current focus areas are access to professional health care, oral health, and healthy nutrition and exercise.

The form below is provided as an example of the kinds of information we request when considering a grant request. Do not use the form to send an uninvited grant request; it will be automatically rejected. Persons interested in Health Fund grant funding must contact a program officer first for authorization before starting a grant application.

Grants for Healthy Kansans Sample Form

Grant Request online submission

Instructions: Please fill out the requested information in each section of the form below. Only one section can be edited at a time. After completing a section, click the "Save Changes and Continue" button to save your entries and continue to the next section.

If you wish to jump directly to a different section and edit it, click the "Edit this section" link for the section you want to work on. Important--be sure to save any changes you have made to the current section before jumping to another section.

Saved information will be held until you are ready to submit the grant request. You can continue work on your request at any time by logging in again. When you are finished with your request, click the link below and follow the submission instructions on that page.

(click this after you finish entering information below)

Last updated: Fri. July 17th, 2005 11:34 AM

Project Basics

Title of Project:
Focus area:
If other, please describe briefly
Amount of request: ($)
Funding timeline:	Start Date
	End Date
Project will continue after grant ends:	Y/N
If yes, how will funding be developed long-term?

Applicant organization information

Please provide basic information about the organization conducting the project.

Organization name:
Address:
City:
County:
State:
Zip Code:
Phone:	(555-555-5555)
Fax:	(555-555-5555)
Email:
Website:
Organization type:	describe below if other
Other:

Key contact for organization

Name:
Title:
Phone:
Email:

Project Director/contact for grant request

Name:
Title:
Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:

Project overview

Population served by the project:
Geographic area served by the project:
Summary of project (1-3 sentences):

Organization's mission and history

Organization's experience in the field of this project

Organization's experience in project field

Project description - type/goals and strategies

Project type:

Broad goals and strategies:

Project description - Evidence of need

Evidence of need:

Project description - Persons served by/benefiting from project

Persons served by/benefiting from project:

Project description - Implementation personnel and qualifications

Persons implementing the project and qualifications for this work:

Project outcomes - Key outcomes expected

Key outcomes expected:

Project outcomes - Progress indicators and measures

Indicators or measures to track progress:

Project timeline (optional)

Timeline:

Project budget - Income

#	Income source	Year 1 ($)	Year 2 ($)	Year 3 ($)	Line total ($)
1	Health Ministry Fund				0
2					0
3					0
4					0
5					0
6					0
7					0
8					0
9					0
10					0
	Totals	0	0	0	0

Project budget - In-kind support

#	In-kind support source/brief description	Year 1 value ($)	Year 2 value($)	Year 3 value ($)	Line total ($)
1					0
2					0
3					0
4					0
5					0
6					0
7					0
8					0
9					0
10					0
	Totals	0	0	0	0

Project budget - Expenses

#	Expense category	Year 1 ($)	Year 2 ($)	Year 3 ($)	Line total
1					0
2					0
3					0
4					0
5					0
6					0
7					0
8					0
9					0
10					0
11					0
12					0
13					0
14					0
15					0
	Totals	0	0	0	0