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Oral Health Grant Application for Safety Net Dental Clinics, Oral Health Programs, Etc.

Date +

Name of Organization

Federal Tax Identification Number (EIN)

501 (c) 3 Organization

Government Agency or Public School

Native American Tribal Organization

Contact Person

Mailing Address

City

State

Zip Code

County

Phone

Program Title

Total Cost of Program

Amount Requested from Delta Dental

Number of individuals to be served

Percentage of Medicaid individuals

Percentage of uninsured individuals

Are you seeking other sponsors?

Yes

If yes, please list sponsor names

and requested amount

In addition, please provide the following information

A brief summary of your organization, including your history, mission, and services provided:

0/200 words

Explain the need and significance of your project:

0/300 words

Outline how the following will be used in the development and implementation of the project:

a. Strategy

b. Demographics of clients (including nonduplicated number of adults and children served)

c. Project detail

d. Methodology

e. Timeline

0/1000 words

Include a budget page for the project, as well as the organization - be specific as to how the Delta Dental grant will be used

List the organizations you are collaborating with on this project and describe how the collaboration will take place:

0/150 words

Describe the expected outcomes or results, as well as the indicators of those outcomes:

0/300 words

Describe the evaluation process and how the results will be measured:

0/300 words

Include a list of all dental professionals providing care. Briefly describe the staff qualifications, especially the project manager.

0/200 words

Describe how the program will be sustained into the future, once the Delta Dental grant has concluded. Will the program receive any government grants or funding?

0/150 words

How will Delta Dental be recognized?

0/150 words

How will you revise the project if full funding is not provided?

0/150 words

List your organization's various insurance coverage and providers (i.e. malpractice, property, liability, board):

0/150 words

How did you hear about our Foundation? Is your organization currently affiliated with, or have you been sponsored by Delta Dental of Wisconsin in the past?

Signature verifying the information submitted is true and accurate:

clear

Attach any additional supporting documentation here.