Community Health Investment Program (CHIP)
Request for funds
• All applications must use this completed form as the cover page.
• On a separate page, please list your board members or principals.
• Complete the Foundation’s application budget page
and attach to your application.
• Please do not include
any supplemental materials (brochures, letters of support, etc.)
• Using no more than two
8 ½ x 11 single-sided sheets of paper, please tell us about your proposal. Be sure
to include the following, and label the information by letter
in your narrative:
a) The mission or purpose of your organization or group
b) A definition of the need, including how the need has been determined
c) The targeted population
d) A description of the project
e) Your expected results
f) Your timetable and process for achieving results
g) How you will evaluate the process of your proposal
Time period of your project: From
Date when funds will be needed:
Total Project cost $
CHIP grant requested $
Other Funding sources
Submit 14 copies
of the completed application, including additional narrative, budget and board list to:
Salina Regional Health Foundation • 400 S. Santa Fe • Salina, KS 67402
In addition, please include 1 copy of the most recently completed financial audit for the applicant organization.
Ouestions? You may find your answer on our website at www.srhc.com. If not, call the Salina Regional Health Foundation
office at 785-452-6088, or email email@example.com.