EmailMe Form - COVID-19 Rolling Funding Application

COVID-19 Rolling Funding Application

As the NAFC receives and continues to develop funding opportunities for our members for COVID-19 responses, we are opening up this application for funding as opportunities become available. This application will remain open as it is rolling, and grant monies will be awarded as funding becomes available to members in good standing of the NAFC.

The following application's emergency funding would be specific to COVID-19 in the following areas:

• Telehealth

• Tests & Equipment

• Medication Access

Important Funding Information:

• Funding will be awarded in grant amounts ranging between $2,500-$10,000.

• Funding must be utilized for COVID-19 related efforts, and specifically for what is submitted through this application.

• Reporting: There will be one (1) evaluation due at the 3-month mark that will ask for information on how the funding was spent, and what kind of impact was obtained.

• Eligibility: organizations must be members in good standing of the NAFC. For more information on membership, please email ariana@nafcclinics.org

Organization Name *
Primary Contact First Name *
Primary Contact Last Name *
Primary Contact Email *
Phone *
### - ### - ####
Organization Mailing Address where you will receive the check *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Organization Physical Address if different from above

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
My organizations is considered a:
Free Clinic
Charitable Clinic
Hybrid Clinic
Charitable Pharmacy
State Association
Other
Is your organization open and seeing patients either in person or through telehealth services?
Yes
No
If you selected NO above, please select the reason(s) below for deciding to close.
Lack of funding
Lack of access to Personal Protective Equipment (i.e. gloves, masks, gowns, etc.)
Concern for High-Risk Volunteers/Staff
Lack of Volunteers/Staff
Other
Is your organization presently testing patients for COVID-19?
Yes
No
Is your organization presently using Telehealth or telemedicine programs to assist your patients?
Yes
No
Please select the funding area for your request. *You may select more than one. *
Telehealth
Tests & Equipment
Medication Access
Amount Requested *
$2,500
$5,000
$7,500
$10,000
Why do you need this funding, and how will you use it? *
BUDGET - Please tell us how you will use the funds. The budget breakdown below should ONLY include information for the requested funds.

***When reading from left to right, column 1 will remain blank, column 2 should contain your description of the item where the funding will go, and column 3 should indicate the amount that will be spent per item requested.
*

Item Requested Monetary Amount Requested ($)

Total:
Terms & Conditions
If granted, your grant is subject to your agreement to:

1. Use the grant funds only as specified in the approved grant proposal.
2. Maintain your records to show and account for the uses of grant funds.
3. Allow NAFC access to records to verify grant expenditures and activities.
4. Provide written acknowledgment of receipt of payments of grant funds.
5. Repay any portion of the funds not used for the specified purposes.
6. Refrain from use of the funds for any purpose prohibited by law.
7. Cooperate with any efforts of the NAFC to publicize the grant award, including but not limited to photos, press releases and visits to your organization.
8. Comply with reasonable requests for information about program activities.
9. Reporting at the 3 month mark.
I agree to the terms and conditions above *
Yes
No