Innovation Grant Application The application form is below. All fields marked with an asterisk are required.1. State applicant organization type:*Chapter/AssociationHTCOther 2. Contact Information In the event that the staff who submitted the grant request leaves the organization during the grant period, the Foundation needs the contact information for a second individual who is responsible for the project.2a. Name of applicant organization* 2b. Address of Organization* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 2c. Address to send check* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 2d. Name of Primary Contact Person* 2e. Telephone of Primary Contact Person*2f. Email of Primary Contact Person* 2g. Name of Secondary Contact Person* 2h. Telephone of Secondary Contact Person*2i. Email of Secondary Contact Person* 3a. Amount Requested: $50,000 MAXIMUM TOTAL.*3b. For collaboration, list partners and how much is included for each, and their role on the project.*List of Partners$ AmountRole 4a. Name of applicant’s authorized institutional/organizational representative* 4b. Signature of applicant’s authorized institutional/organizational representative* Reset signature Signature locked. Reset to sign again 5. Organization description: *brief* description of mission, geographic service area, # served.*6. *Brief* description of the project.*7. *Brief* description of the need that the project addresses.* For item 8 below, concisely state the specific outcomes or measurable objectives of the project. How will you measure the success of the project? Well-conceptualized and clearly stated outcomes and objectives will receive higher consideration. If you are unfamiliar with writing outcome or measurable objectives, you may refer to the following CDC article. Note that clicking the link will open the CDC's PDF in a new browser tab. https://www.cdc.gov/std/Program/pupestd/Developing%20Program%20Goals%20and%20 Objectives.pdf8. Timeline for project completion*9. Concisely state the specific outcomes or measurable objectives of the project.*10. Statement of how the project will strengthen the care of persons with blood disorders.* 11. Itemized Budget - Format - This is total budget for project that is requested from the Hemophilia Alliance Foundation. *Cannot exceed $50,000. Item Description & Calculation Detail* $ Amount*Item Description & Calculation Detail2 $ Amount2Item Description & Calculation Detail3 $ Amount3Item Description & Calculation Detail4 $ Amount4Item Description & Calculation Detail5 $ Amount5Item Description & Calculation Detail6 $ Amount6Item Description & Calculation Detail7 $ Amount7Item Description & Calculation Detail8 $ Amount8Item Description & Calculation Detail9 $ Amount9Item Description & Calculation Detail10 $ Amount10Total Amount Requested12. Budget Narrative - Itemized description of each budget item including names of staff and consultants and their roles on project.* *Cannot exceed $50,000 See Sample Budget Here. Be sure to include required attachments specified in the Guidance THE APPLICATION MUST BE SUBMITTED ONLINE. ONCE COMPLETED, THE REPORT MUST BE SUBMITTED ELECTRONICALLY BY PRESSING THE “SUBMIT” BUTTON AT THE BOTTOM OF THIS FORM. YOU WILL RECEIVE AN ELECTRONIC CONFIRMATION OF RECEIPT. After clicking the “Submit” button below, a notification email, along with a link to a PDF of this form submission, will be sent to the email that you’ve entered into the “Email for primary contact person” field. However, the PDF can only be accessed from the same computer that was used to submit this form. This is a security measure to prevent unauthorized downloads. Therefore, if you are submitting this form on behalf of someone else and have input their email address into the “Email for primary contact person” field, then they will need to email the PDF link to you so that you can access it from your computer. If after submitting the form you don’t receive a notification email in your Inbox, then please check your spam folder and whitelist the email address “info@hemophiliaalliancefoundation.org”. YOU ARE RESPONSIBLE FOR MAKING SURE YOU RECEIVE THIS ACKNOWLEDGEMENT OF RECEIPT.Please attach the required document below. Note: your document MUST be in PDF format. Attaching files in another format will result in an error screen.IRS Determination Letter*Accepted file types: pdf, jpg, jpeg, Max. file size: 256 MB.W-9*Accepted file types: pdf, jpg, jpeg, Max. file size: 256 MB.Letter of collaboration – This is required for collaborative projects. A letter is required from each tax-exempt eligible collaborating partner for which funding is requested. The letter must state the role and budget for each collaborating partner.Accepted file types: pdf, jpg, jpeg, Max. file size: 256 MB.Additional letter of collaborationAccepted file types: pdf, jpg, jpeg, Max. file size: 256 MB.Letter of support – A letter of support is recommended but not required from an organization or entity whose participation is important to the project, but is not receiving grant funding.Accepted file types: pdf, jpg, jpeg, Max. file size: 256 MB.Additional letter of supportAccepted file types: pdf, jpg, jpeg, Max. file size: 256 MB.To submit your application, click the "Submit" button below. If you'd like to save your progress and continue the application later, click the "Save and Continue Later" link. Doing so will take you to a page that will display a unique link. You'll need this link to return to your application. You can copy and paste the link into a word processing document for safe keeping or you can have it emailed to an email address of your choosing. Note that clicking the "Save and Continue Later" link will save all of your progress except for the file attachments. Those need to be attached just prior to submitting the application. Note also that if someone other than yourself needs to sign the application, you need only send them the unique Continue link and they'll then be able to access the form and sign it. They can then either click the "Save and Continue Later" link - at which point you can return to the form using the Continue link - or click the "Submit" button.Acknowledgement* I acknowledge that this application will not be considered without all required documentation and attachments.CommentsThis field is for validation purposes and should be left unchanged.
