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Grant Interest Form

* Denotes required fields
Person making the grant request
Contact person
* Is this request for programmatic support or for research?
Do you have a funding opportunity in mind?
* Has your administrator or CEO approved of the request for grant funding assistance?
* Has your CFO approved of the request for grant funding assistance?
Please complete the following questions. Please provide explanation where necessary.
Will grant funding be used to purchase equipment? If yes, please describe.
Will grant funding be used to pay for personnel time?
Will the project include construction of any kind? If yes, please describe.
Will the facility be able to contribute a cash match or in-kind support for the project? If other, please describe.
Is the grant-funding project part of a larger initiative or project at the facility? If yes, please describe.
Will the project include partnership with other departments, facilities, or organizations? If yes, please describe.
Is there a telehealth component to this project?
Does your facility have any relationships with funders or organizations that could provide funding? Or, are there any possible funders based in your community? If yes, please describe.
Has planning for this project already begun? If so, please describe planning efforts thus far.

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Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian values.

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