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Community Support Funding Application
Organization and Contact Information
Name of Organization (full name, no abbreviations)
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Mission Statement
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0/150 words
Organization Mailing Address Line 1
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Address Line 2
City
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Zip Code
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The following fields should be completed by the person who can answer questions about this application.
First Name
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Last Name
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Title
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Phone Number
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Email Address
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Event/Initiative/Program Information
Event/Initiative/Program Name
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Mission Alignment
Describe how the mission of the organization aligns with MetroHealth's mission and vision.
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0/150 words
Event Overview
Describe the goals of this event/initiative/program.
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0/150 words
Who is the target audience for this event/initiative/program?
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Event Date
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Event Time
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What is the location of this event/initiative/program?
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How many people are expected to attend this event/initiative/program?
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Priority Areas
Which priority areas will be addressed? Select the most appropriate response.
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Healthcare
Social Drivers of Health
Health Equity
None
If you have selected None, please list the need that will be addressed by this event/initiative/program.
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Priority Health Issues
Does the event/initiative/program address any of the following? Select the most appropriate response
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Mother/Baby Health
Addiction and Behavioral Health
Trauma or Violence
None
Robust Partnership
How does this event/initiative/program create or enhance partnership between your organization and MetroHealth?
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Describe how this event/initiative/program provides an opportunity for MHS leadership and staff to engage with the community. (check all that apply)
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Staff Resource Table
Volunteer
Speaker Opportunity
Provide Direct Services
Other, please specify
For other, please specify how this event/initiative/program provides an opportunity for MHS leadership and staff to engage with the community.
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Budget/Sponsorship Request
What is the amount of the funding request?
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What will the funding be used to support?
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What proportion of your funding request is equal of your total budget?
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What other sponsors have you secured/approached to support your project?
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How will the organization communicate MetroHealth’s support to stakeholders and the community? (check all that apply)
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MetroHealth logo on material
Advertisement in a publication
Social Media post(s)
Website post(s)
Other, please explain
Other ways the organization will communicate MetroHealth's support to stakeholders and the community.
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Accountability
I/we attest that the organization will provide after event/initiative/program information as requested by MetroHealth
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Yes, we will provide information as requested
No, we will not be able to provide information
Has this organization received funding from MetroHealth previously for this event, initiative or project?
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Yes
No
If you have received funding from MetroHealth for this event/program, please list the year(s) and the amount awarded each year.
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0/150 words
Conflicts of Interest
To help us assess potential conflicts of interest, are there any MetroHealth employee(s), MetroHealth System and/or MetroHealth Foundation board members who are represented on your organization’s governing board(s) or who are otherwise employed/compensated by the organization?
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Yes
No
If there is a potential conflict of interest, please identify their relationship to your organization.
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0/150 words
Please upload any additional files for consideration (e.g. flyers, brochures, sponsorship packages)