Funding Application

Community Health Committee Funding
Apply for funding to help us achieve a healthier community — together.

Community Health Committee Funding Application

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

Organization Name*
Contact Name*
First Last
Executive Director Name (if different from Contact)
First Last
Contact Phone*
Contact Email*

Note: Email is required to apply online. If you do not use email, please contact Selynto Anderson, Community Prevention & Wellness Services Manager at 864-725-4164 or send application to Community Health Committee, 1325 Spring Street, Greenwood, SC 29646.
Please define the measurable outcomes and reporting of those specific outcomes for your project.
501(c)(3) Confirmation*
- By checking this box, I acknowledge that my organization is a valid 501(c)(3) charity and I am able to submit proof of that nonprofit status.
501(c)(3) Status Document*
Accepted file types: pdf.
Please upload a PDF document showing proof of your 501(c)(3) status.
Liability Considerations*
- By checking this box, I affirm that my project does not involve liability to Self Regional Healthcare except to provide the amounts of the Community Outreach grant.
Fiduciary Considerations*
- By checking this box, I affirm that my project does not involve the establishment of a permanent foundation or trust or a permanent interest-bearing account or involve an attempt to influence legislation.
Requested Funding Date*
Date Format: MM slash DD slash YYYY

Note: The requested funding date must be at least 90 days from application date.
Please identify all other possible funding sources, if any:
We require a completed W-9 in order to consider your application. If you do not already have a W-9 form, you may download one from the IRS website:
https://www.irs.gov/pub/irs-pdf/fw9.pdf
Please Provide your Organization's W-9*
Accepted file types: pdf.
Please provide a W-9 for your organization so we can report the funding as required by IRS code.
Cover Letter*
Accepted file types: pdf.
Please submit a cover letter for your project.
Two-Page Project Proposal*
Accepted file types: pdf.
Please provide a two-page proposal for your project including an outline and timeline for the project, description of partnerships and documentation, definition of outcomes measurement criteria, plus a simple project budget.
Requirements of the Recipient*
- By checking this box, I understand that Self Regional Healthcare shall be credited graphically for all programs, events and products produced. The Self Regional Healthcare logo should also be incorporated on products, reports, or other collateral. At the end of the grant period it is requested that a final report be submitted using measurement criteria to describe the success of the program. If a project cannot be completed within a reasonable time frame, funds will be returned to the committee to be made available for other projects.
Comments
This field is for validation purposes and should be left unchanged.