Santiam Service Integration Funding Request Form

Welcome to Santiam Service Integration Funding Request Form. We value our partners and are thankful Santiam Families have advocates such as you! If you have questions about this form or need assistance filling it out please contact Melissa Baurer, Santiam SIT Coordinator, mbaurer@santiamhospital.org or 503-769-9319
 
Basic Funding Guidelines

Service Integration Team dollars are intended to meet an immediate one time need that achieves a measurable outcome towards health, wellness, and/or self-sufficiency. SIT funds are a last resort when all other community resources have been accessed or unavailable.

The online request form is intended for community partners and service providers only. If you are needing assistance with a personal need please contact The Salvation Army (503-585-6688) or Marion County Resource Center (971-273-7345).  

Measurable Outcomes

Service Integration funds should be focused on meeting needs that can provide some measurable outcome (whether big or small).
 

Before submitting a request please read the Service Integration Funding Process Form and Service Integration Funding Guidelines. 

* 1. Referring Agency/Provider Contact Information

* 2. Type of Request(s): Example; Rental Assistance, car seat, car repair, etc. Enter dollar amount requested for each item

* 3. Total amount of funding requested? (please provide a specific $ amount)

* 4. When is the funding needed by?

Date / Time
/
/
:

* 5. What Service Integration Team are you requesting funds from? 

* 6. Is this request urgent? (if possible please allow request to be addressed at next SIT meeting)

* 7. Please provide a detailed description of what the funds will be used for. What is the family/individual's circumstances? How will this improve their well-being, health, or self sufficiency?

* 8. How will the individual or family pay for this expense the following month?

* 9. Please list all other community resources that have been accessed for this request prior to bringing it to the SI teams

* 10. Funds contributed/leveraged to this specific request. List all agencies, organizations, or businesses contributing to this request. Include what their contribution is and the value of their contribution. Please include discounted costs or rates from the agency providing the service if applicable.

* 11. How many people will this request serve?

* 12. What is the age of the individual(S) living in the home?

* 13. What services/resources is the individual/family receiving?

T