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10716-ultrasound-application Layout 1

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ULTRASOUND
PROGRAM
APPLICATION
GENERAL INFORMATION
Please indicate which matching funds program option being applied for:
_____ Ultrasound Machine Funding
_____ Ultrasound Machine and Vehicle Funding for Mobile Unit
Sponsoring state/provincial or local council: __________________________________________ Number: _________
Council location: _________________________ State/Province ________ e council voted to approve proceeding
with fundraising for this program on (date): ____________________
Contact Person: _______________________________ Title: _____________________ Date: ________________
Telephone #: ________________ Address: _________________________________________________________
Pregnancy Center: _______________________________________ Telephone: _____________________________
Contact Person: ______________________________ Title: ________________ Email: _____________________
Address: ____________________________ City/Town: ___________ State/Province: _______ Zip Code: ________
U.S. – Tax Status: ____ 501(c)(3) ____ Other: _________________ PCC’s U.S. Tax ID # (EIN): ________________
Canada – e Canadian Revenue Agency (CRA) has approved this PCC as a registered charity authorized to
perform limited medical services: (circle) Yes No Canadian Registered Charity #:______________
National Affiliations: (circle) NIFLA Care Net Heartbeat other: ____________________________________
( _____ ) is pregnancy center has no policies that are anti-Catholic in any way and does not engage in practices that
would tend to lead Catholic women away from their faith.
( _____ ) is pregnancy center does not advocate or refer for birth control.
Does the pregnancy center require ( ________ ) employees, ( ________ ) volunteers or ( ________ ) patients/clients
to sign a Statement of Faith?
Yes ____ (If yes, please enclose a copy.) No _____
LIFE
FAITH IN ACTION
FAITH IN ACTION
LIFE
ULTRASOUND MACHINE FUNDING
Please verify each of the following statements and indicate with a checkmark:
_____ e center complies with all state/provincial/local laws/regulations to operate an ultrasound machine.
_____ e pregnancy center’s medical director is: Dr. _______________________________________
Address: ___________________________________
_____ e machine will be staffed with trained, licensed, and experienced medical personnel.
_____ e pregnancy center will offer limited diagnostic medical services, not non-diagnostic/entertainment services.
_____ e center has adequate insurance for operation of the ultrasound machine.
Ultrasound Machine Manufacturer: ___________________________ Model: ______________________________
Type of ultrasound machine to be purchased: 2D ____ 3D ____ 4D ____ other ___________________________
List price: $________________________ Check: ____ new ____ refurbished ____ portable
Machine’s actual cost (not including freight, taxes, training, salaries, etc.): $__________________________
Please list the council number of any other councils which assisted in or contributed to the state council’s/ council’s
fundraising efforts. # ______________ # ______________ # _______________ # ______________
Briey describe anything particularly noteworthy about the pregnancy center (near abortion clinic, colleges, military
base, etc.) and the major fund raising programs used by your council (use additional paper if needed):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Total amount raised to date by the council (must be at least 50% of the machine’s actual cost): $ _________________
FAITH IN ACTION
LIFE
VEHICLE FUNDING FOR MOBILE UNIT
(If not applicable, skip to next section)
Vehicle type: (circle one) Bus RV Truck Van other: ________________________________
Vehicle Manufacturer: _________________________ Model/Year: ________________________________
(circle one) Purchased: New Used Leased Donated other: _______________________________
Obtained from: (circle one) Manufacturer/Dealership ICU Mobile Save the Storks
Private Seller other: __________________________
Original list price of vehicle/mobile unit: $_________________________
Actual purchase price (aer discount, if any) of vehicle (not including registration, fees, taxes, driver costs, maintenance,
fuel, etc.): $_________________________
Does vehicle come fully equipped to offer ultrasound services? (Circle) Yes No
If no, describe conversion work done/to be done: ______________________________________________________
____________________________________________________________________________________________
Total estimated/actual costs to convert vehicle to mobile medical unit: $ ______________
Total mobile unit costs (vehicle + conversion expenses, if any): $ ______________
Has the council completed fundraising to cover the full cost of purchase/purchase and conversion of the vehicle/mobile
unit? (Circle) Yes No
If yes, what is the total amount of funds raised by the council? (Council funds raised + expected Supreme Council grant,
must equal or exceed the total cost of purchase/purchase and conversion expenses for the mobile unit, including the cost of the
ultrasound machine) $ ________________________
Please verify each of the following statements and indicate with a checkmark:
_____ e mobile unit complies with all state/provincial/local laws/regulations regarding registration/operation of a
mobile medical unit. e vehicle will park on private property and/or t in intended public parking spaces in
compliance with local zoning and parking laws and permitting processes.
_____ If required, the pregnancy center will seek certication of the mobile unit by health/housing authority inspection.
_____ e mobile unit will be driven by licensed, experienced, insured drivers.
_____ e mobile unit has adequate motor vehicle insurance.
Briey describe anything particularly noteworthy about the mobile unit, including how/where it will be used (use
additional paper if needed): _______________________________________________________________________
___________________________________________________________________________________________
FAITH IN ACTION
LIFE
10716 6/18
GRANT AMOUNTS
A. Ultrasound Machine (50% of the actual cost of the machine): $ ________________
B. Mobile unit (if applicable):
(e lesser of: the purchase price of the vehicle, plus conversion
expenses (if any), or, 50% of the actual cost of the machine): $ ________________
Total grant amount (Lines A + B) requested from Supreme Council Office: $ ________________
Please make the Supreme Council’s check for matching funds payable to: ___ the pregnancy center listed above; or,
___ (State Council Charity) ____________________________________ EIN/Charity #____________________
Please mail check to (name/address): ________________________________________________________________
____________________________________________________________________________________________
State Deputy’s signature: ________________________________________ Date: __________________________
Email a copy of this document to: fraternalmission@kofc.org
(Councils should also retain a copy of this completed form for their les)
Enclosures:
1. Ultrasound Machine Price Quote
2. Vehicle Price Quote (if applicable)
3. Documentation for estimated/actual costs of conversion expenses (if any)
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Completed 3 June 2020

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