Step 1 of 6 16% ORGANIZATION PROFILEName of qualified organization* Contact person* Title* Email* PhoneOrganization website: Annual operating budget Tax ID Number Year of incorporationMailing address Number of employees (full/part-time) Number of volunteersBoard Chair Name Board Chair Start/End Date Number of board membersAudited Financial Date: (if yes, please attach) MM slash DD slash YYYY Please attach most recent audited financials.Max. file size: 50 MB.990 Tax Filing Date: (please attach) MM slash DD slash YYYY Most recent Form 990Max. file size: 50 MB. REQUEST:Grant request:Children to be served by grant:Location of the program Mission Trip: Yes No Mission Trip Dates ORGANIZATION MISSION: PROGRAM REQUEST:Please outline your board philosophy in maintaining organizational sustainability (i.e., fund donation, production and/or service donations). Not to exceed 250 words. Describe stakeholder support and how the project may impact the priority of increasing surgical care to children. Not to exceed 250 words.Describe stakeholder support and how the project may impact the priority of increasing surgical care to children. Not to exceed 250 words. PROGRAM DETAILS If the request is for an ESTABLISHED PROGRAM, provide the following:Name of in-country hospital: How long has program been established: Surgeon: Cardiologist: Local program coordinator(s): In-country Coordinator Name(s)PhoneEmail US-based Coordinator Name First Last PhoneEmail If the request is for a MISSION TRIP provide the following:Name of in-country hospital: Surgeon(s) & name of home country hospital of practice: Cardiologist(s) & name of home country hospital of practice: Number of medical professionals attending:Will the organization apply for travel grants from other resources for medical professionals: Y/N Yes No Local program coordinator(s): Phone/Email: GOALS & OVERSIGHT:How will you measure progress?State the goals, objectives, and evaluation plan. Not to exceed 250 words.What defines program success?Provide details on how you measure outcomes. Not to exceed 250 words. ACCOUNTABILITY:Explain how ongoing follow-up of children served will be implemented. Not to exceed 250 words. PROGRAM IMPACT:What is the impact your program has on the community it serves?Explain country demographics and the impact this program will have on this region. (e.g., number of children on a waiting list, expected long-term changes that will occur as a result of this work) Not to exceed 250 words.What is the long-term plan for this program?Provide a detailed plan on how this program is/will be sustainable. Not to exceed 250 words.COLLABORATION:What partnerships currently exist or need to be established to implement this program? Not to exceed 250 words. Allowable funds requested based on annual revenue: $1 - $200,000: request not to exceed 50% of budget $200,001 - $800,000: request not to exceed 45% of budget $800,001+: request not to exceed 25% of budget Specify how funds will be used.SurgeriesCatheterizationsPatient InsurancePatient HousingPatient TravelScreeningMedicationsFollow up careConsumablesMedical Team AirfareMedical Team Ground TransportationMedical Team LodgingShipment for SuppliesOtherPlease detail other funds requested. OtherPlease detail other funds requested. OtherPlease detail other funds requested. OtherPlease detail other funds requested. Signature*Submitted By Email PhoneDate MM slash DD slash YYYY By signing my legal name above, I acknowledge that I have read and understand the policies as contained herein. Here's a preview of your submission: {all_fields}
