School-Based Health Center Grant Application 2.1

1. Grant Application Form
Date of Application*

MonthDayYear
Date
Name of LEA:*
Name of School:
LEA's Unique Entity Identifier (UEI):*
# of Schools in LEA:*
LEA Total Enrollment*
Does your school or LEA have a federally identified classification of CSI, TSI, or Promise, or are you identified as a rural school district?*

YesNo
If yes, select all that apply:*

CSITSIPromiseRural district
Name and Title of Person to Contact Regarding this Proposal:*

Full NameTitle
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Amount Requested (up to $10,000):*
Numeric characters only

2. Application Narrative
View the narrative component descriptions and scoring rubric on pages 8-9 of the Request For Applications (RFA).
A. Community Resources and Demographics Relevant to the Need for a SBHC*
B. Description of the Six-Month Planning Process*
C. Proposed Partnerships/Partners*
D. Planning Outputs/Deliverables*
E. Planning Project Timeline of Key Activities and Milestones*

Budget Guidelines

Grants will be approved for a 6-month planning period up to the amount of $10,000.
Budget must include line items related to grantee participation in the three required in-person post-award meetings in Atlanta, GA (i.e., mileage and hotel, if applicable; meals will be provided during meetings).
Allowable costs: grant facilitator/convener, meeting facilitation, communications (i.e., postage, printing of flyers), community engagement activities, travel, office supplies, etc.
Non-allowable costs: Because this is a planning grant, funds cannot be used for clinic implementation (space renovation, furniture, medical and office equipment/supplies, and any other clinic operations).

SBHC Planning Grant Budget Sample

INCOME
Source	Amount
Government Funds	$
Foundation Grants	$
Georgia Department of Education Planning Grant	$
Corporation Contributions	$
Individual Contributions	$
Fundraising Events	$
In-Kind Support	$
Total Income	$

EXPENSES
Source	Amount
Travel Mileage Hotel	$ $ $
Supplies	$
Printing & Copying	$
Postage & Delivery	$
Community Engagement Expenses	$
Other (Explain)	$
Other (Explain)	$
Other (Explain)	$
Total Expenses	$

Budget Narrative (Provide a brief description of each budget line item).

Please upload the budget and budget narrative here.*

File formats accepted: .pdf, .doc, .docx
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4. Supporting Documentation
Required Supporting Documentation

A. An introductory cover letter describing the purpose and amount of the request signifying full support from district leadership, signed by the LEA Superintendent.

B. Letter of Support from the school principal of the chosen school with assurances that a suitable location has been identified and dedicated for this purpose (either in the school building or on the school campus for a modular building site).

C. Letter of Support from an identified medical sponsor (Federally Qualified Health Center, hospital system, community physician) who has agreed to serve in this capacity.

D. Letter of Support from a parent or parent organization expressing their commitment to planning and implementation.

E. Job description (if applicable) for personnel who will be supported by planning grant funds (i.e., facilitator, convenor, etc.)
Please upload supporting documentation here.*

File formats accepted: .pdf, .doc, .docx
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Review and Submit
*** Before submitting, please review your application for accuracy and verify that all necessary documentation is attached.
By entering your name here, you are attesting that you understand and agree to all rules and requirements of this grant opportunity. *

First NameLast NameSuffix
Please verify that you are human*
Should be Empty:

School-Based Health Centers Grant Application Round 2.1