Community Health Committee Funding

Apply for funding to help us achieve a healthier community — together.

The Self Regional Community Health Committee meets quarterly to discuss funding proposals from nonprofit organizations within our 7 county service area.

The investment proposals under consideration by the Self Regional Community Health Committee (CHC) shall contribute to achievement of one or more of the following goals:

Increase the treatment, prevention and/or early detection of diseases and conditions that affect significant portions of Self Regional’s service area.
Proactively promote healthy lifestyles and reduce the conditions resulting from unhealthy lifestyles such as obesity, cardiovascular disease, drug and alcohol abuse, tobacco use, teen pregnancy, child abuse / neglect, etc.
Address the Social Determinants of Health that affect our patients and communities based on SRH’s organizational efforts and its most recent Community Health Needs Assessment (CHNA).

Please review our CHNA Criteria for Funding. For more information, please call (864)725-5469.

Funding Request Timelines

Request should be made 90 days prior to anticipated funding.

Application Due Dates:
January 1st for April Funding Meeting
April 1st for July Funding Meeting
July 1st for October Funding Meeting
October 1st for January Funding Meeting

Community Health Funding Application

This form enables non-profit organizations to apply for Community Health project funding through the Self Regional Community Health Committee. Revised January 2022.

Organization Name(Required)

Funding Request Application Checklist

1. IRS, Not For Profit 501 (c ) (3) approval letter(Required)

Max. file size: 20 MB.

2. Most Recent Filed Tax Form 990 (if applicable)

Max. file size: 20 MB.

3. Business Plan or Budget(Required)

Max. file size: 20 MB.

4. Most recent Audit Report (if applicable)

Max. file size: 20 MB.

5. Most recent Financial Statements(Required)

Max. file size: 20 MB.

6. Proof of Professional Liability Insurance(Required)

Max. file size: 20 MB.

Funding Request Details

Submitter Name(Required)

First Last

Submitter Title(Required)

Submitter Email(Required)

Contact Phone(Required)

Project Title(Required)

Project Start Date(Required)

Funding Amount Requested(Required)

Project Goals and Outcomes(Required)

Goal Measurements:(Required)

Questionnaire

1. What is the Mission of your organization?(Required)

2. Describe how your organization aligns with the focus areas identified in the Community Health Needs Assessment, as outlined on the Self Regional Healthcare website.(Required)

3. What is your geographic area served and target population?(Required)

4. Please provide a list of your Board Members.(Required)

5. List all Funding or Grants awarded (with amounts) and other Grant applications submitted.(Required)

6a. Itemize how your funding request will be used (if not included in Business Plan).(Required)

6b. Describe the need for future funding requests.(Required)

7. What is the date your organization was established?(Required)

8. Number of Employees in Organization?(Required)