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 #:
Alcohol and other drug use Oral Health Physical Activity
Mental Health Injury and violence prevention Chronic disease prevention and management
Access to health services Nutrition
AMOUNT REQUESTED $(minimum $10,000):
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. Begin each section with numbered statement with information to follow. All information must be factual and accurate as reported.

  1. Describe the agency requesting funds, its mission, and how long the organization has been in existence.
  2. Explain what the requested funds will specifically be applied toward including program/project goal(s).
  3. Provide a statement how the project addresses a current community/health need or improves health and wellbeing of Washington County. Identify and include the number of individuals and/or families who will benefit and communities served. Washington County Health Needs Assessment can be found at:
  4. Clearly state the anticipated/expected outcomes or results (include measurable data).
  5. Describe the evaluation process and how results will be measured (include data and or tools/samples).
  6. Explain plans to ensure the sustainability of the program/project (if ongoing).
  7. Describe any collaborations or affiliations with other organizations/partners and the role that organization will play specific to this program/project.
  8. Share any potential recognition opportunities if funding is received to promote the partnership and collaboration with Froedtert & the Medical College of Wisconsin St. Joseph’s Hospital and Healthy Community Fund.

Supporting Documents

The following must be submitted with your completed funding application (10 Copies).
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 Cover Sheet
  • 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 on September 28, 2018 between 9am and 2pm at St. Joseph's Hospital 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.
  • Application deadline is 1:00 pm on September 14, 2018. Late applications will not be accepted
  • Please submit 10 copies of the Application Form and supporting documents requested.
  • Funding application should include numbered responses with headers that correspond with the items (1-8) from the Funding Request Summary.
  • Do not include staples, report covers or report folders (paperclips 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.
  • Submit 10 copies by 1:00 p.m. on the deadline to:
    Andrew Dresang
    St. Joseph’s Community Engagement
    3200 Pleasant Valley Road
    West Bend, WI 53095
  • If questions, call 414-777-1926 or email:

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.