Grant Request Form

Fill out the grant request form below. You will be informed of the disposition of your request within one week of the next Aspirus Riverview foundation Board Meeting. Before you begin, be sure you are prepared to enter the following information into the form, or upload appropriate documents that indicate:

• A list of the board of directors of your organization.
• A list of the officers of your organization.
• Relevant financial information (i.e., detailed breakdown of projected expenses, price quotes, etc.).
• A brief history of your organization.

* indicates required field

Requestor Information

Name of organization making request: *

Address: *

• City: *
• State: * Please select state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming
• Zip: *
• Name/title of individual making request: *
• Phone:
• Email: *

Do you have a non-profit status – 501(c)(3)? *

Request Details

Amount being requested: * $.00

Which priority does your request address? * -- select -- Substance Use Behavioral Health Active Communities and Community Food Systems

How will your request address this priority? *

How will you use the funds requested? Program? Project? Equipment? Be specific: *

SMART goals for project: *

Number of people to benefit from funding: *

Is the Riverview Foundation being asked for the total funding needed? *

Will you be requesting funds from any other source? *

Will you be using any of your current funds? *

Is this a one-time request? *

Would you expect to make subsequent requests? *

Organization Information

Please provide a list of the board of directors of your organization in the field below. If you prefer, you can upload a file with this information in the corresponding field below. If you are uploading a file, enter "see attachment" in the text field below: *

Board of Directors upload:

Please provide a list of the officers of your organization in the field below. If you prefer, you can upload a file with this information in the corresponding field below. If you are uploading a file, enter "see attachment" in the text field below: *

Officer upload:

Please provide relevant financial information (i.e., detailed breakdown of projected expenses, price quotes, etc.). If you prefer, you can upload a file with this information in the corresponding field below. If you are uploading a file, enter "see attachment" in the text field below: *

Financials upload:

Please provide a brief history of your organization. If you prefer, you can upload a file with this information in the corresponding field below. If you are uploading a file, enter "see attachment" in the text field below: *

History upload:

Please provide any other information you feel the Board should know about your organization or project: *