Grant Application Form

Primary Contact Name Email Phone

Medical Leader Name Email Phone

Faith Leader Name Email Phone

Location of Project Region and City Country

Projected Impact Number of people receiving direct care Number of people educated Number of people trained

Project Funds Amount Requested

Will there be local contribution?

Local Contribution Description (goods or money)

Project Summary Describe what you and your team plan to do with your project. (Note: You can provide some background details, but keep this part very brief)

Accountability Who else in community will be able to confirm the funds were used as described? What measures are in place to assure the integrity of funds?

Collaboration What other organizations or groups are involved? What church is involved in the project? How will the local community be engaged?

Sustainability How will the project and its related activities continue once the grant funds are gone?

Innovation What is unique about this project? (Can be an entirely new idea or just new to an area)

Gospel spreading How does this project advance the spreading of the Gospel?

Zero in on Zero

Please complete the form for EACH disease you plan to address in your project. You will need a SEPARATE plan for each disease. You can borrow from the SMM presentations to complete this with evidence-based plans, and you can add in parts to fit your culture. But, these should all be plans that can be tested and verified. Remember: The Zero in on Zero plans are “What” you will do and not “How” you will do it. How you will do it is your implementation plan. Remember: This is not a timeline. You are deciding what needs to be done “Before treatment”, “During treatment”, and “After treatment” Tip: Some community, education and behavior items may appear both Before and After If you are planning on more than two diseases, you can copy one of the following pages to complete your Zero in on Zero plans

Disease 1 Name of Disease Before/During/After

Disease 2 Name of Disease Before/During/After

Disease 3 Name of Disease Before/During/After

Project Budget

Please provide as much detail as you are able. For example, do not list “medications”. Instead list the specific kind of medication you plan to purchase. Help us understand exactly what you are purchasing. Avoid general categories that do not describe what is being bought. (Note: You are free to use your own budget format, but is must show the same breakdown of costs per item and quantity)

Details Grand total of all items