Fiscal Year 2019 Hamilton Center Foundation Mini-Grant Application Form

Instructions

Complete each of the areas below and attach a quote or cost estimate if applicable. Mini-Grant requests may be made for up to $1,000 for equipment/supplies, a service, program or project that will ultimately enhance the quality of care and satisfaction for Hamilton Center consumers. Please note that only Hamilton Center programs are eligible to receive these mini-grants.

Applications must be received by 5 p.m. on June 1, 2019. You will be notified of the funding decision by July 1, 2019. There will be 20-25 awards. For more information, contact Lynn Hughes at ext. 8338 or lhughes@hamiltoncenter.org.

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* 1. Mini-Grant Request

Title of Request (Name of Project/Equipment):

Amount requested:

Total cost of the project/equipment:

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* 2. Contact Information:

Your Name:

Extension:

Office/Program

Program Manager or employee responsible for overseeing the use of funds:

Extension (if different from above):

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* 3. Describe the request in detail.

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* 4. Describe the need(s) that prompted this idea.

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* 5. If the total cost of the project/equipment is more than $1,000, how with the remainder of the costs be funded?

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* 6. Who will benefit from the grant? Be specific and include actual numbers, if known.

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* 7. How will this funding improve the quality of consumer care and satisfaction at Hamilton Center?

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* 8. Has the Chief and/or Executive Director over this program area given approval to submit this mini-grant application?

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* 9. If question 8 is marked yes, please provide the name of the Chief and/or Executive Director:

Approval of this application includes acceptance of the Mini-Grant Award Terms and Agreement detailed below.

Mini-Grant Award – Terms and Agreement:

By approving and submitting the Mini-Grant Application, the program manager (or designee) named on the application agrees to be the contact person for this request and agrees to the following terms, should the mini-grant request be approved:

1.      Funding must be used within 1 year of the Mini-Grant award. Hamilton Center Foundation must be notified if funds are not used, or to request an extension or change of use of funds.

2.      The funds awarded by the mini-grant will be reimbursed to the department as follows:

   a)      The grant money will be put in a “specific purpose” account managed by the Fiscal dept.

b)     The department will purchase the items/services covered by the grant and either ask the fiscal dept. to cut a check by completing the “Foundation Check Request” Form (Under Accounting forms on Intranet) or by purchasing items by credit card and submitting the receipt to fiscal with “Specific Purpose Foundation Grant funds” noted on receipt.

3.      A Follow‐Up Report is required for all approved funding requests.

a)      The Follow‐Up Report must be submitted to the Foundation office within 30 days of use of funds/start of project.

b)     The Follow-Up Report should describe the effect this funding has had on consumers and/or the department.

c)      It is strongly recommended that photos, consumer stories, or other collateral material be included in the report so that the Foundation can show the community the good work being done.