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

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

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:
Mailing address: (If PO Box) Physical Address:
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?

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?

Please describe your request for funding:
Please provide an event/project summary, along with date(s), audience demographics and community impact.
Does this service/ program already exist in the community? If so, have you collaborated with the others involved to eliminate duplication? How?
How will you measure success of this projector program?
What outcome data in terms of qualitative and quantitative measures will be
captured to show overall impact on community?
What is the amount of your request?
Additional required information
What is your organization’s mission statement?
Please provide a list of board members, indicate if St. Rita’s employees.
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