CCHA | Application

Legal status of organization *

Public School

501(c)(3)

For-Profit

Other

Region *

Region 6 (Boulder, Broomfield, Clear Creek, Jefferson, Gilpin)

Region 7 (El Paso, Park, Teller)

Primary County

Boulder

Broomfield

Clear Creek

El Paso

Gilpin

Jefferson

Park

Teller

Proposal Summary

Provide a summary of the proposed project. Briefly describe why your organization is requesting funding, what results you hope to achieve, how you will spend the funds and how the project contributes to both your overall mission, as well as the mission of CCHA and the Regional PIAC.

A brief description of the purpose and history of the organization *

Organization’s mission and goals *

Board roster *

Number of paid full-time staff and/or paid part time staff *

Goals and objectives of project *

Timeline for implementation *

Specific activities to be funded *

Outcomes expected *

The populations that you plan to serve and estimated number of Health First Colorado members *

How Health First Colorado members will benefit from the project *

Approaches, methods, and activities planned for the project *

Names, titles, qualifications and experience of key personnel *

Any plans for sustaining the project and for long-term sources/strategies for funding upon completion of the proposed funding *

Other organizations, if any, participating in the project *

Explain the project’s expected results and how you will measure the effectiveness of your activities through quarterly report to Regional PIAC (quantitative and/or qualitative data) *

How the dollars will align with CCHA’s KPIs, Behavioral Health Incentives *

Policies & Financial Information

The following information must be with the submission of this form.

Non-discrimination Policy *

Current W-9 *

Most recent annual statements (audited if available) *

Current operating budget *

A detailed budget of this project *

A list of other sources of actual and expected funding, including amounts *

A copy of your current IRS determination letter indicating tax-exempt status, if applicable

Any additional supporting attachments

CCHA Community Incentive Program Application

Information requested from application:

Proposal Summary

Policies & Financial Information