AHSV Grant Application

Community Benefit Grant Application

Grants are intended for 501c3 non-profit organizations to apply for a specific contribution for a special purpose that aligns with Adventist Health Simi Valley’s mission, values, and areas of focus. Eligible funding could include a project, activity, or education and ineligible costs include administrative costs, rent, utilities, insurance, and salaries.
Organization Name*
Mailing Address (where check should be sent if request is approved)*

Address

Address Line 2

CityState / Province

Postal / Zip Code
Contact Name*

First NameLast Name
Contact Person Phone Number*

Area CodePhone Number
Email*
example@example.com
Is your organization a 501c3?*

YesNo
Federal Tax ID #*
Please upload your organization 501c3 IRS Status Determination documents (pdf, jpg)

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Where is your organization located?*

Ventura CountyOther
100% of grant funds will be used in what city? (choose all that apply)*

Simi ValleyMoorparkThousand OaksOther
What areas of focus does this grant apply? (choose all that apply)*

Access to CareHealth ConditionsMental HealthOther
Please provide a detailed explanation of your request.*
Grant Amount Request*
Has your organization been awarded a grant before?*

YesNo
How does the work of your non-profit organization align with Adventist Health Simi Valley’s mission and focus areas listed above? *
How does your request provide community benefit?*
Describe how your request advances health equity.*
What goals will this grant help your organization accomplish?*
Will you be able to spend grant dollars within a calendar year?*

YesNo
A requirement is to submit a year-end report of how the grant funding was used. Can you provide a year-end report?*

YesNo
Please submit the following documents to support your grant request and how this grant will be used as a community benefit.
- Mission Statement
- Community Need and Benefit statement
- Executive Summary
- Sustainability Plan (goals, objectives, and outcomes)
- Target Population
- Budget
- Methods for Measuring Success
Support Documents

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Upload any additional documents that would support your sponsorship request. Cancelof
If your request is approved, who should the check be made out to? *
Organization name, as it should appear on the check.
Please provide any additional information you feel would be helpful or relevant to this request:
By providing your details and clicking "Submit" you agree to:
- Receive communications from Adventist Health through email, SMS, text, or calls by an automated telephone dialing system for the purpose of Adventist Health maintaining its relationship with you and providing you information related to services you may be interested in.
- Adventist Health collecting and disclosing to third parties personal information and communications for the purpose of fulfilling your inquiries or requests for services or information.
Should be Empty:

Community Benefit Grant Application