EmailMe Form - 2022 Valuing Services Mini-Grant Application

2022 Valuing Services Mini-Grant Application

IAFCC is piloting a Valuing Services Project that will provide our member clinics with a data collection tool that is both scalable on a national level and relevant on a clinic level.

Purpose of mini-grant: To support Illinois FCC’s in demonstrating the impact of their FCC services and care.

In order to receive grants clinics must submit:
1. Membership Application
2. Required documents
3. Submit IAFCC Membership Fee (Paypal or Mail)
4. Submit mini-grant application below

Please reference the table on the membership renewal page of our website to determine your membership fee and mini-grant request.

https://www.illinoisfreeclinics.org/for-members/2022-membership-application/

Clinic
Contact Person Name
First Last
Position/Title
Email
Phone Number
### - ### - ####
Mailing Address (where to send your check!)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Clinic Operating Budget
$ Dollars
Membership Fee
$ Dollars
Mini-Grant Requested
$ Dollars
What would you use your mini-grants for? (Purchasing equipment, paying for staff/intern time, etc.)
How will your clinic sustain data collection and use for future years?
How will this benefit your clinic internally?
How will this benefit your clinic externally?
As a recipient of the IAFCC Valuation Grant and authorized representative for the award, I agree to the following terms:

- To use the funds for the purpose stated in the completed IAFCC application.

- To complete a short report on use of the clinic dashboards and mini-grants by September 15, 2022. The report will include: how the funds were used, a sustainability plan, and process improvement feedback.
I agree
I do not agree to these terms.
I give IAFCC permission to share information of this report in IAFCC external communication regarding the Valuation Project.
I agree
I do not agree to these terms.