Community Benefit Grant Application

Please complete application form below by 4 p.m. on the dates below:

March 8
May 31
September 6
November 15

Applicants will be notified within four weeks if they will receive a grant.

The following documentation is required:

IRS letter of determination 501(c)(3)
Names of your organization's board members, terms of office and compensation, if any
List of key staff members and your organizational chart
Completed grant application form
One example of each of the following (if available):
- Annual report
- Organizational brochure
- A balance sheet and income statement covering your organization's most recently completed fiscal year

Please email all of the documentation to: ammornings@premierhealth.com

Organization Name *

Federal Tax ID *

First Name *

Last Name *

Mailing Address

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

Phone number *

Email address *

Organization Website Address *

Social Media Addresses

Organization's Current Budget *

Project/Program Budget* *

Requested Amount *

Executive Director/CEO

Executive Director/CEO Name *

Executive Director/CEO Email address *

Select a title *

Executive Director
CEO

Contact for Application

Contact Name *

Contact Title *

Contact Phone number *

Contact Email address *

Purpose of your proposal/request *

State the purpose of your proposal/request in no more than two sentences.

Funding Category *

Community Health Improvements
Community Building Activity

Community Health Improvements - Community activities or programs that respond to community needs and seek to achieve objectives including; improving access to health services, enhance public health, advancing increased general knowledge.

Community Building Activity - Community-building activities improve the community's health and safety by addressing the root causes of health problems, such as poverty, homelessness, environmental hazards, etc. These activities strengthen the community’s health and social fabric, fostering collaboration, trust, and shared responsibility among residents. By empowering individuals and organizations to work together, these activities create a supportive environment that promotes long-term well-being, resilience, and sustainability, ultimately improving the overall quality of life for all community members.

Title of Project/Program *

Target Population *

Define the target population for your initiative and how it will reach those that are most vulnerable to the health issue you are trying to improve.

Strategies *

What evidence based strategies are being utilized and how will it improve the health of the target population? How will you measure the health improvement?

Collaboration *

Identify the collaborating entities associated with this initiative. Please note any financial and/or in-kind contributions to your initiative.

Alternative Plan for funding *

Define your alternative plan if funding is not granted from Premier Health.

Timetable *

Define your timetable for your initiative/program development, implementation, and measurement.

Certify Entry *