St. Rita’s Medical Center
Application for Community Investment

Community Investment On-line Policy

Organizations requesting funding support must complete this application form
(located at StRitas.org).

Thank you for the work you already do in our community.

CONTACT INFORMATION
As an anchor instution it is our mission to improve the health and well-being of our communities by seeking to address root causes of poor health and removing barriers, such as the Social Determinants of Health, which oftentimes lead to poor health, economic and racial inequities. Our hope is that by being intentional, our communities will thrive, and we will help to build inclusive and sustainable economies.
Official name of organization:
Non-profit status:	Yes No
Mailing address: (If PO Box) Physical Address:
Address:
City:
State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
Name of person submitting application:
First Name:
Last Name:
Role in the organization:
Phone Number:
Email Address:
Will this request help to address social determinants of health in our community?	Yes No
If “Yes”, which Social Determinant of Health will it help to address?	Education (literacy, vocational training, internships, etc.) Food (hunger, access to healthy options) Neighborhood & Physical Environment (housing, transportation, safety, playgrounds, ZIP code/geography) Community & Social Context (community engagement, support systems, etc.)
Please explain how this request will impact a social determinant of health:
If “No”, are there programs that you currently offer that help to address one of the social determinants above?
Under which identified area of focus should this request be considered?
Community Health Needs Identified Community Health Priorities: Chronic Disease; Mental Health & Addiction; Maternal & Infant Health; Prevention and Health Behaviors (exercise, nutrition, weight, etc.) Community Health Education Health education, smoking cessation, nutrition, education of health professionals, etc. Community Development Community Economic Development (access to care, workforce development initiatives, neighborhood revitalization, etc.) Care for the Poor Support services for people living in poverty
Please describe your request for funding:
1. Please provide an event/project summary, along with date(s), audience demographics and community impact.
2. Does this service/ program already exist in the community? If so, have you collaborated with the others involved to eliminate duplication? How?
3. How will you measure success of this projector program?
4. What outcome data in terms of qualitative and quantitative measures will be captured to show overall impact on community?
5. What is the amount of your request?
Additional required information
1. What is your organization’s mission statement?
2. Please provide a list of board members, indicate if St. Rita’s employees.
3. Please provide list of other supporting/ sponsoring organizations.
In addition with the organization’s application, organizations seeking support must provide: • A copy of the organization’s W-9 Form • A copy of the organization’s IRS tax exemption determination letter