Regional Core Centers Grant Application InstagramThis field is for validation purposes and should be left unchanged.Please note: ALL items and fields are REQUIRED and must be completed!1. Region-- Select Your Region --Great Lakes StatesGreat Plains StatesMid-Atlantic StatesMountain StatesNew England StatesNorthern StatesSoutheast StatesWestern States 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.a. Name of applicant organizationb. Address of organization Street Address Address Line 2 City State / Province / Region ZIP / Postal Code c. Address to send check if that differs from the organization’s address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code d. Name of primary contact persone. Telephone of primary contact personf. Email of primary contact person g. Name of secondary contact personh. Telephone of secondary contact personi. Email of secondary contact person 3. Amount Requested. $10,000 maximum for the eight federally-designated and funded regional core centers.4a. Name of authorized Individual4b. Signature of authorized Individual5. Organization description: brief description of geographic service area, # HTCs in area, and estimated # patients/families served (if available).6. Brief description of the need that project funds are intended to address. Example: There are 5 of the 22 HTCs in the region that do not have 340b programs and we will be helping to pay for their travel.7. Brief description of the regional meeting. Include number of days planned, #HTCs/persons expected to participate, format (in-person vs. virtual), venue, how topics/agenda are chosen (participation of HTCs?), including plans for topics and activities to be included, as can best be described at this time.8. How will you measure/evaluate the success of the project? Briefly describe data collection methods (qualitative/quantitative).9. Itemized Budget. Itemize each budget item and amount, including personnel names, if known. Budget applies ONLY to HAF funds. Do NOT include other sources of funding. Personnel expenses up to but not exceeding 25% of the total grant request and incurred exclusively for grant-related activities will be considered. Consultants and speakers are NOT considered personnel and should NOT be counted toward personnel expenses. Follow the sample budget or SEE SAMPLE BUDGET OF THE GRANT GUIDANCE. Click on (+) to add more rows if needed.Description$ Amount Add RemoveTotal Amount Requested10. Budget Narrative: Include the name and role of each of the listed personnel, Their salary/hourly charge, and all equipment, travel, supplies, and other expenses with details. Be sure to include required attachments specified in the Guidance. Note: your uploaded documents MUST be in PDF, JPG, or JPEG format. 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.Acknowledgement(Required) The grant applicant acknowledges and agrees to comply with all applicable state and federal laws including but not limited to the Federal Anti-Kickback Statues as found in Section 1128 D(b) of the Social Security Act and 42 U.S.C. Section 1330a-7b(b). Note 1: After clicking the “Submit” button below, a notification email will be sent to the Primary Contact Person’s email address that includes a copy of your report in PDF format. The PDF will be attached to the email. Note 2: 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.Copy of your IRS Determination Letter or 501(c)(3) Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB. Copy of your organization’s W-9 Drop files here or Select files Accepted file types: pdf, jpg, jpeg, Max. file size: 32 MB.
