Community Health Committee Grant Application

Applications for the current grant cycle are accepted from October 1 through December 31, 2026. Before you begin, review who can apply and what the committee funds .

The application has four steps — organization, project, budget and documents, and declaration. Have these ready to upload: your 501(c)(3) determination letter, W-9, most recent tax return, organizational annual operating budget and financial statements. Files can be PDF, Word, Excel or images, up to 10 MB each. A copy of your application is emailed to you when you submit.

1Organization

2Project

3Budget & Documents

4Declaration

Name

This field is for validation purposes and should be left unchanged.

Organization Information

Project Title(Required)

Name of Organization(Required)

Executive Director / CEO(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Grant Contact Person(Required)

First Last

Phone Number(Required)

Email(Required)

A copy of your application will be sent here.

Website

If applicable.

Tax ID Number (EIN)(Required)

Mission Statement(Required)

I. Project Overview

Project Summary(Required)

Provide a detailed summary of the project, including the need(s) it will address. Include relevant data. 500 words maximum.

Number of Individuals(Required)

How many individuals do you plan to impact or engage with the project?

Please enter a number greater than or equal to 0.

Geographic Service Area(Required)

For example, a neighborhood, a town, or county-wide.

If your program was designed to serve a specific population, please indicate it below. Leave these blank if it was not.

Race / Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White, non-Hispanic

Other

Gender

Female

Male

Age Group

Children – Preschool (0–4 yrs.)

Children – Elementary School (5–10 yrs.)

Youth – Middle School (11–13 yrs.)

Youth – High School (14–17 yrs.)

Young Adult / College (18–22 yrs.)

Adult (23–59 yrs.)

Senior (60+ yrs.)

Not Age Specific

II. Goals & Objectives

Goals and Objectives(Required)

List the goals and objectives of the project (up to 5). 500 words maximum.

Community Health Committee Goals Addressed(Required)

Select every goal the project supports.

Goal 1: Increase the treatment, prevention, and early detection of diseases and conditions that significantly impact Self Regional’s service area.

Goal 2: Proactively promote healthy lifestyles and reduce the prevalence of conditions associated with unhealthy lifestyles.

Goal 3: Address the Social Determinants of Health (SDOH) based on Self Regional Healthcare’s organizational efforts and its most recent Community Health Needs Assessment (CHNA).

Alignment with Committee Goals(Required)

How do the project goals align with the goals selected above? 500 words maximum.

III. Activities & Outputs

Activities and Outputs(Required)

Describe the proposed activities and their outputs, with quantitative data where applicable. Include a detailed plan of action, a timeline for implementation, and the community partnerships involved. 500 words maximum.

IV. Outcomes & Impact

Outcomes and Impact(Required)

Describe the outcomes and impact of the project, with both quantitative and qualitative data. What community impact or results are you committed to achieving during the grant period, and how will you know you have succeeded? 500 words maximum.

VI. Sustainability

Sustainability(Required)

How will the project be sustained beyond the funding period? 500 words maximum.

V. Budget and Financial Report

This replaces the Attachment 1 budget worksheet. Totals are calculated for you.

Total Amount Requested(Required)

The grant amount requested from the Community Health Committee.

Please enter a number greater than or equal to 0.

Other Funding Sources

Total from all other sources identified for this project.

Please enter a number greater than or equal to 0.

Other Sources of Funding Identified(Required)

List each other source, its amount, and whether it is secured or pending. Enter “None” if there are none.

Personnel

Please enter a number greater than or equal to 0.

Equipment

Please enter a number greater than or equal to 0.

Supplies

Please enter a number greater than or equal to 0.

Travel

Please enter a number greater than or equal to 0.

Training

Please enter a number greater than or equal to 0.

Other Expenses

Please enter a number greater than or equal to 0.

Expense Details(Required)

Give a breakdown of each expense category above, including what “Other Expenses” covers.

Total Revenue

Total Project Cost

Funding Gap

Total project cost minus total revenue.

Required Documents

PDF, Word, Excel or image files, up to 10 MB each.

501(c)(3) Determination Letter(Required)

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, Max. file size: 10 MB.

W-9(Required)

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, Max. file size: 10 MB.

Most Recent Tax Return(Required)

For example, Form 990.

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, Max. file size: 10 MB.

Organizational Annual Operating Budget(Required)

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, Max. file size: 10 MB.

Financial Statements(Required)

Your most recent financial statements.

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, Max. file size: 10 MB.

Detailed Project Budget

Optional, if you have a fuller budget than the worksheet above.

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, Max. file size: 10 MB.

VII. Additional Information

Additional Information

Anything else you would like to provide in support of your application. Optional. 500 words maximum.

Supplementary Materials

Optional. Up to 5 files.

Drop files here or

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, Max. file size: 10 MB, Max. files: 5.

Declaration

Certification(Required)

I understand that any false information provided may result in the rejection of this application.

I certify that the information provided in this application is accurate to the best of my knowledge.

Signature(Required)

Type your full name. This serves as your signature.

Date(Required)

Prefer to apply offline? Download and complete the Grant Application Template (fillable 13-page PDF) , then email the completed application and required documents to grants@selfregional.org.

Use the subject line: FY27_SRH Community Grant Application_[Your Organization Name].

Application Questions

Email: grants@selfregional.org

Grant Management Office

Brittni King, MPH
Grant Coordinator
864-725-7897 · brittni.king@selfregional.org

Andria Wendell, MPH
Grant Programs Manager
864-725-7895 · andria.wendell@selfregional.org

What can wehelp you find?

Community Health Committee Grant Application

Organization Information

I. Project Overview

II. Goals & Objectives

III. Activities & Outputs

IV. Outcomes & Impact

VI. Sustainability

V. Budget and Financial Report

Required Documents

VII. Additional Information

Declaration

Application Questions

What can we
help you find?