Supporting Health and Wellness in our Community

Application Form


Form should serve as cover sheet for funding request. One application may be submitted per agency.

Requesting Organization Information

Requesting Organization:
Contact Name:
Organization Address:
City: State: Zip:
Daytime Phone:
Email Address:
Tax Indentification #:
PROGRAM/PROJECT NAME:
PROGRAM/PROJECT COMMUNITY HEALTH NEED PRIORITY (check all that apply):
Alcohol and other drug use Oral Health Physical Activity
Mental Health Social Determinants of Health Chronic disease prevention and management
Access to Health Services Nutrition

PROGRAM/PROJECT TARGET POPULATION (check all that apply):
Youth Families Military/Veterans General Population
Seniors Low Income Homeless Other:
Latinx Uninsured Disability
AMOUNT REQUESTED ($10,000 minimum):
Is this a single or Multi-year (Note: Multi-year projects are not guaranteed funding for consecutive years.)
Partial funding accepted? Yes No
Please list any other funding requests or pending requests (include any other Froedtert Health entity):

Duration of Project: Start date: // End date: //



Funding Request Summary

Please provide a summary of information to the numbered items below. All information must be factual and accurate as reported.

  1. Describe the agency requesting funds, its mission, populations served and how long the organization has been in existence. (750 word limit)
  2. Explain how the funds will be used including program/project goal(s). (1000 word limit)
  3. Describe how this program/project is unique in Washington County and why your organization is the most qualified to deliver the program effectively. (750 word limit)
  4. Reason this program/project is needed and how it benefits the health of Washington County. Describe the target population and number impacted. The Washington County Health Needs Assessment can be found at: https://www.froedtert.com/community-engagement/west-bend-hospital. (1000 word limit)
  5. Clearly state the anticipated/expected outcomes or results (include measurable data). (1000 word limit)
  6. Describe the evaluation process and how results will be measured (include timeline, data and or tools/samples). (1000 word limit)
  7. Explain plans to ensure the sustainability of the program/project (if ongoing). (500 word limit)
  8. Describe any collaborations or affiliations with other organizations/partners and the role that organization will play specific to this program/project. (500 word limit)
  9. Share any potential recognition opportunities if funding is received to promote the partnership and collaboration with Froedtert & the Medical College of Wisconsin Froedert West Bend Hospital and Healthy Community Fund. (500 word limit)

Supporting Documents

The following must be submitted with your completed funding application. Print 10 copies and deliver to Froedtert West Bend Hospital, First Floor Information Desk:
Andrew Dresang
Community Engagement
Froedtert West Bend Hospital
3200 Pleasant Valley Road
West Bend, WI 53095

Information submitted will only be viewed by Healthy Community Fund Committee and kept confidential. Failure to provide all components of application requirements will void your application.

  • Application Form
  • Program/project budget
  • Agency’s annual financial statement
  • List of Board of Directors
  • List of paid staff
  • Signature from Executive Director and Board President

Important Submitting Information

  • Organizations that meet the application requirements will be invited to attend an interview session to provide additional information and answer questions from the Healthy Community Fund Committee regarding your application. Your agency will be contacted with an interview date and time.
  • Late applications will not be accepted.
  • Applications that have been previously submitted may be re-submitted for consideration as long as information is still accurate and no more than 12 months has lapsed since last submitted.
  • Email application by 1:00 p.m. on the deadline to Andrew Dresang: andrew.dresang@froedtert.com.
  • Print and send 10 copies of your supporting documents by 1:00p.m. on the deadline.
  • Late applications will not be accepted.
  • If questions, call 414-777-1926 or email: andrew.dresang@froedtert.com

If award is received, failure to use funds as identified will result in the loss of opportunity to submit future requests. A summary report outlining the success of the program/project with specific outcomes and measurable data will be requested.