Our Lady of the Lake Regional Medical Center's
Community Benefits Application
Organization
*
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Mission Statement of Organization
(500 characters max)
0/500
Is Your Organization a 501(c)3 Non-Profit?
Yes
No
Have you received funding from our organization before?
Yes
No
If yes, when and how much funding did you receive?
Name of Our Lady of the Lake Regional Medical Center's team member main advocate
Each application must have an Our Lady of the Lake Regional Medical Center's team member who will serve as the advocate and main contact/support for the request. If no advocate has been identified, enter N/A in this blank. Our Lady of the Lake Regional Medical Center's will assign a team member to research the request. Allow an extra two weeks for requests requiring additional research.
Tell us about your event or your reason to request funding.
Event Name or Reason for Request
Please provide a brief overview of the project and/or event.
To which Community Health Needs Assessment Priority Area(s) do/does your funding request apply?
Health Equity / Racial Disparities
Behavioral Health
Social Determinants of Health
Violence Prevention
Maternal and Infant Health
How much are you requesting to assist with your cause?
How specifically will the funding be used?
How will the funds help advance this cause?
How will you measure the success of this project / event?
Date and Time of Event
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Is this the first year for your event?
Yes
No
If no, briefly describe past attendance, success and number of years held.
Is the event open to the public?
Yes
No
How many people do you expect to attend or be served by this project?
Briefly describe the demographics of who will be served through this project and/or event.
Please upload a copy of your organization's annual report.
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Please upload a copy of your organization's W-9.
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Please include the filled Ownership Acknowledgment Form here (required).
*
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Please include the filled Supplier Supplement Form here (required).
*
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Please include any other supporting documentation regarding your request.
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