Community Service Grant Application

Section 1: Applicant Information

1.1 Organization Name:

1.2 Organization Address

Street Address Line 1 Street Address Line 2 City State

1.3 Contact Information:

Primary Contact Name: Position/Title: Phone Number: Email Address: 1.4 Organization’s Mission Statement:

1.5 Tax Status:

Tax Status If "Other," please specify:

Section 2: Project Information

2.1 Project Alignment with ToRCH Goal (please check which goal(s) your project aligns with):
More follow-up visits: Increase follow-up visits within 30 days for Medicaid members with a high mental health score in the Emergency Department
Fewer chronic illness cases: Lower the number of Medicaid members with hypertension by 1%
Fewer chronic illness cases: Lower the number of Medicaid members with diabetes (HgbA1c) by 1%
More well-child visits: Increase well-child visits for Medicaid members after the third year by 1%
Fewer missed appointments for pregnant women: Reduce missed appointments for pregnant women with Medicaid by 1%

2.2 Project Title: 2.3 Project Summary: 2.4 Target Community/Population:

2.5 Project Dates

Start Date

Day

Month

Year

End Date

Day

Month

Year

2.6 Total Project Budget: 2.7 Amount Requested from This Grant: 2.7.A Will these funds be required for sustainability? 2.8 Project Activities: 2.9 Expected Outcomes and Impact:

Section 3: Financial Information

3.1 Detailed Budget (Please attach a detailed budget outlining project expenses and funding sources, including other grants if applicable): 3.2 Financial Statements (Attach the most recent financial statements for your organization):

Section 4: Additional Documents

4.1 Project Plan (Attach a detailed project plan, including timelines and milestones): 4.2 Letters of Support (Optional: Attach any letters of support from community leaders, stakeholders, or partners):

Section 5: Certification and Acknowledgements

I certify that the information provided in this application is true and complete to the best of my knowledge and belief. I understand that any misrepresentation may result in disqualification from the grant process.

I acknowledge that I will present a quarterly progress report on this project to the ToRCH Leadership Board. Reports are due on the last day of the month following the quarter (April 30 for Jan.–March; July 31 for April–June; Oct. 31 for July–Sept.; and Jan. 31 for Oct.–Dec.). Reporting is required until funds are used or depleted.

I acknowledge that to be eligible for a ToRCH community service grant, my organization must fully participate in the Unite Us platform and address referrals in a timely way.

Signature:

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Date

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