Minnesota Dental Foundation Grant Application

Please fill in all fields and submit online when completed. Please note that no handwritten applications will be accepted. All applications must be submitted online.

Organization Information

Name of Organization*

Legal Name, if different

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Website

Contact Name*

First Last

Contact Title*

Contact Phone*

Contact Email*

Is your organization an IRS 501(c)(3) not for profit?*

Yes
No

Is your organization an educational institution, public agency, or unit of government?*

Yes
No

EIN*

Budget Information

Amount requested (in dollars)*

Are you seeking, or do you have matching funds?*

Yes
No

Total project budget (in dollars)*

Total annual organization budget (in dollars)*

Proposal Information

Project Classification*

Access to Care
Prevention/Education/Intervention
Treatment Programs

What type of treatment/activity are you proposing?*

Where is the treatment/activity going to be provided?*

Who is doing the work? Any use of volunteers?*

Expected number of children <12 served:*

Expected number of teens 12-18 served:*

Expected number of adults 19-65 served:*

Expected number of seniors > 65 served:*

Expected number of patients physically challenged:*

Expected number of patients cognitively challenged:*

Geographic area served*

Please select project type*

Direct patient care (other than GKAS)
Give Kids a Smile (GKAS)
Dental assisting/hygiene education project
Other

If other, please specify:*

Project dates*

Fiscal year-end*

Is this the first year of this program?*

Yes
No

If not, when did you start this specific program?

Please provide the goals you hope to achieve through your program/project and describe how they fit with the Minnesota Dental Foundation’s vision of eliminating unmet oral health needs in Minnesota. If a GKAS application, describe the services you will provide. Finally, describe briefly how you plan to measure your program/project outcomes. (Limit of 1500 characters).*

By signing this grant request, you certify that you are authorized to submit grants on behalf of your organization. * I understand and certify that I am authorized to submit grants on behalf of my organization.*

I agree

Signature of person completing this application*

First Last

Title*

As a condition of receiving any award, you must file a report on how these funds were used within four months of the completion of the project.