Healthy Sacramento Coalition
Community Contracts Application Form
Application deadline: July 25, 2012, at noon
Read the Request for Applications carefully before completing this application.
Application Cover Sheet
To complete this form, save this document in Microsoft Word and type into each shaded field.
Use the TAB key to move from field to field, or click in each field. Limit your Cover Sheet
responses to the space provided.
Applicant Information
Organization
Address
City
Phone
Director
Tax Exempt ID#
Web site
State
Ext
Zip Code
E-mail
Title
DUNS#
www.
Application
Contact
Organization
Address
City
Phone
Title
State
Ext
Zip Code
E-mail
Project Summary Information
Brief Purpose of Project (limited to 190 characters): Grant funding will be used:
To
Amount Requested (up to $7,100)
Community
Check the box next to the community where funded activities will take place.
Citrus Heights
Elk Grove
Folsom
Galt
Isleton
Rancho Cordova
Sacramento (city); specify neighborhood, if applicable:
Unincorporated Sacramento County; specify neighborhood, if applicable:
All of Sacramento County
 Use the organization name currently registered with the IRS.
Sierra Health Foundation
1
Application Materials Checklist
Healthy Sacramento Coalition Community Contracts Application materials, to be submitted in
this order:
Completed HSC Grant Application Form (use the form provided and submit in Word or
PDF format ONLY), which includes:
− Application Cover Sheet
− Application Narrative
− Project Budget and Budget Narrative
− Performance Measures table
501(c)(3) determination letter (submit as an attachment in PDF format)
If an item on the checklist is not applicable, please briefly explain:
Submit all materials in the checklist above by attaching them to an e-mail and sending to
[email protected].
Include the applicant organization name and the telephone number of the person sending
the application e-mail in the body of the e-mail so we can contact you if we have
questions.
Name of authorized 501(c)(3) organization officer
Title
Sierra Health Foundation
2
Application Narrative
Please answer each of the following questions completely and succinctly. Limit your responses to a total of
two pages.
1. Provide a brief overview of your organization, a) when it was established, b) your organization’s mission, c) whom you
serve, d) geographic area your organization serves, and e) the types of programs you provide. Include examples of
ways your organization has been successful in its work; for example, what has changed as a result.
2. Describe the community your organization will represent in the Healthy Sacramento Coalition with these funds (give
us a clear picture of their circumstances, and describe their age, gender, ethnicity, socioeconomic situation, where
they live and any special circumstances). Specifically describe how your organization will ensure this community’s
involvement in the Healthy Sacramento Coalition.
3. Describe how your organization proposes to ensure the participation of the community you represent in the Healthy
Sacramento Coalition’s Community Health Assessment activities. (List specific proposed activities and how they will
be measured in the Performance Measures table on page 5).
4. Describe cooperative relationships needed for the proposed activities to be successful. Have these been
established? Who are your community partners for this project? How long have relationships been in place? What
do the partners bring to your efforts? If cooperative relationships are not needed, please explain.
Don’t forget to complete the Proposed Project Budget and Budget Explanation.
Sierra Health Foundation
3
PROPOSED PROJECT BUDGET AND BUDGET EXPLANATION
Requested from
Sierra Health
Foundation
Total
Project Budget
I. Personnel
Salaries (list position)
1
2
3
4
5
6
Payroll Taxes and Benefits
Consultant Fees
1
2
3
4
Total Personnel
II. Other Expenses
Office Supplies
Postage
Printing/Duplicating
Information/Materials
Equipment
Rent/Utilities
Travel
Miscellaneous (list)
1
2
3
4
5
6
Total Other Expenses
Total Grant Expenses
BUDGET EXPLANATION
FOR EACH ITEM EXPLAIN HOW THE FUNDS WILL BE USED FOR THE ACTIVITIES.
Shaded field will expand as you type and continue on to additional pages.
Sierra Health Foundation – Healthy Sacramento Coalition
4
Sierra Health Foundation – Healthy Sacramento Coalition Community Contract Performance Measures Form
All contractors will be required to report on key performance measures for their grants. Fill in the table below with your best estimate of the
proposed activities’ impact. These will be your goals. As you identify performance measures for the proposed project, consider how, when and
where the data will be collected and who will collect it. This table will expand as you type and continue on to additional pages.
Organization Name:
Purpose of Project (same as on cover sheet):
Part I – Activities and Measures
Proposed Project Design
Performance Measures
For each activity, indicate how you will measure your work.
1. Support the participation of targeted communities in the Community Health Assessment process
What will you do? (List major activities specific to the Sierra
Health Foundation-funded project)
How much will you do? (List measures in
terms of numbers of people reached or
activities performed.)
How will you do it? (List measures to show the
percent of each activity that will be
accomplished.)
2. Ensure communities are represented in and knowledgeable about the Healthy Sacramento Coalition’s efforts
What will you do? (List major activities specific to the Sierra
Health Foundation-funded project)
How much will you do? (List measures in
terms of numbers of people reached or
activities performed.)
How will you do it? (List measures to show the
percent of each activity that will be
accomplished.)
3. Actively participate in Healthy Sacramento Coalition meetings
What will you do? (List major activities specific to the Sierra
Health Foundation-funded project)
Sierra Health Foundation
How much will you do? (List measures in
terms of numbers of people reached or
activities performed.)
How will you do it? (List measures to show the
percent of each activity that will be
accomplished.)
5