Project Summary (300 Words Or Less)

Lead Organization Information

Organization Legal Name: Parent Organization (if applicable): Address: City: Zip Code: Phone Number: Fax Number: Website: Tax Status: 501(c)(3) 509(a)(1) 509(a)(2) 509(a)(3) EIN: Number of Locations: Principal Purposes and Services of your Organization:

Target Population Served: Primary Service Other Service Area: Area: No. of Persons Served No. of Services Provided Annually: Annually: Organizations Mission (100 words or less):

Executive Director / CEO Name: Title : Email: Telephon e:

Grant Application Contact Name: Title : Email: Telephon

The Healthcare Foundation for Orange County© rev 6/30/15 | Lead Organization Information e:

Board Membership & Staffing Number of Board Members: Number of Full-time Number of Part-time Employees: Employees: Number of Contractors: Number of Active Volunteers:

Organization Financial Information

Fiscal Sponsor (if any): Organization Fiscal Year:

Project Information

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Project Summary (300 words or less):

Project Dates: Project Start Date: Click here to enter a Project End Date Click here to enter a date. date. Is this a collaborative project? Yes No

Project Lead or Primary Contact Information: Name: Title: Email: Telephone :

Secondary Project Contact Information: Name: Title : Email: Telephon

Project Financial Summary

Funds requested from HFOC: $ Funds requested from other sources: $ Total project budget (add two lines $ above): Willing to accept partial funding:

By signing below, I certify the information contained in this application is true and correct to the best of my knowledge.

Signature of CEO/ Executive Director Date

Project Target Population

Geographic Area Tustin Santa Ana Anaheim Orange Other Population previously served by Western Medical Center Explai n

Demographics of primary population being served by this project

Age Group 0 – 5 Early Childhood 6 – 11 Middle School 12 – 25 Youth/Young Adult 25 + Adults

Ethnicity African American

The Healthcare Foundation for Orange County© rev 6/30/15 | Lead Organization Information Asian/Pacific Islander Caucasian Hispanic/Latino/South & Central American Southeast Asian Other :

Gender Male Female

HFOC Objective Areas Please check each item this project seeks to address: Empower parents and caregivers with information and support to assure family health Bring culturally relevant information and services into communities Remove barriers to healthcare Address community health priorities and delivery system gaps Assess the changing health needs of women, children, and adolescents to develop effective health strategies