Community Health and Wellness Grant Application Nonprofit organizations located and providing services in Los Alamos County may request up to $5,000 to fund initiatives that enhance the health and well-being of the Los Alamos Community. This funding is intended to empower local nonprofits which are currently or plan to implement innovative and impactful programs to address pressing health issues, promote wellness, and foster equitable access to health resources. Eligible activities include but are not limited to initiatives or activities that align with the following health priorities: mental health and emotional wellbeing, disease prevention, food security, equity and access, health promotion, community health collaboration. Grants are funded by the Anchorum Health Foundation Donor Advised Fund. Before submitting this application, please make sure your organization (or fiscal sponsor) is current with all state and federal reporting requirements including being in good standing with the IRS, NM Secretary of State and NM Attorney General. Please contact us with questions. BEFORE YOU BEGIN! Please print this page or copy the questions below and complete the narrative answers in a separate file, then copy and paste the answers into the form below once you are ready to submit. There is no 'save' feature on the application form - you must complete and submit the form in a single session. Contact Information Applying Entity Name * Tax ID Number of Entity or Fiscal Sponsor * Primary Contact Name (First) * Last * Phone * Email * Address * Address Street Address 1 Street Address 1 Street Address 2 Street Address 2 City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Project Information Project Title * Requested Amount * Provide a brief summary of the project and the work to be completed (project scope). (125 word limit) * 0 of 125 max words Detail the project components and how (and by whom) they will be accomplished. Tie the work to the attached project budget. (500 word limit) * 0 of 500 max words Explain how the project will improve long-term health and wellness in Los Alamos, including: (a) how did you identify the need or deficit you're trying to address; (b) how do/will you know the project addresses the need/deficit; and (c) why can't the need be addressed within your current budget/operations (why do you need this funding?). (500 word limit) * 0 of 500 max words Briefly describe how this project will improve the organization’s ability to serve its mission. (250 word limit) 0 of 250 max words Please share anything else you would like us to know about this funding request. Explain any funding or other partnerships here. (500 word limit). 0 of 500 max words Financial Information Has your organization received funding from LACF in the past? * Yes No If so, please list the years that funding was received Is your organization using a fiscal sponsor? * Yes No If you are using a fiscal sponsor, provide name below Attach the most current operating budget for the organization. (You may attach a Word document, Excel spreadsheet, or .pdf document.) * Drop a file here or click to upload Choose File Maximum file size: 33.55MB Please provide a project budget, including (and distinguishing) expenses to be covered by this grant and any other revenue sources. (You may attach a Word document, Excel spreadsheet, or .pdf document.) * Drop a file here or click to upload Choose File Maximum file size: 33.55MB Certification By completing the fields below, the applicant certifies that the submission of this funding application has been authorized by the organization’s Chief Executive and/or Board of Directors. Name of Authorizing Person * Title of Authorizing Person * Authorization Date * Captcha Submit If you are human, leave this field blank.
