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:
Should be Empty:

Community Benefit Grant Application