Sample Application Overview

Mount Zion Campus–Community Partnership Awards: The following information is required to complete your online application. This page is for planning purposes only. All new requests must be submitted online here or renewal requests, here.

MZ Campus – Applicant Name(s)* and titles Community Partner – Applicant Name(s)* and titles
Division/Dept Agency Name
Phone
Email

Phone
Email
Mailing Address Mailing Address
Alt. Contact(s) and titles Alt. Contact(s)
*Please indicate primary contact name & email for content questions about this application
Name and email for Mount Zion Program Head (e.g., Chief of Service, Center Director, Division Chief, or Department Chair) to be contacted to verify that the UCSF partner is MZ-based program/faculty/staff
Project Title Start and end date of requested one-year grant period
Total Project Budget
Total Amount Requested
Amt Requested from MZHF payable to MZ Campus Partner
Amt Requested from MZHF payable to Community Partner
Executive Summary (in 1-3 sentences state the main goal(s) of the requested funding; also include a brief overview of each partnering entity and briefly describe the partnership history, e.g., why was it formed; how do the partners collaborate, etc.):
  1. Explicitly benefits underserved communities. Describe the project and its purpose, including the unmet health need, target population, and the estimated unduplicated numbers to be served (explicitly state how the project advances the health of one or more underserved populations who have limited access to quality health services because of inability to pay, health status, race, religion, language, gender identity, or sexual orientation).
  2. Based at or in partnership with the UCSF Mount Zion Campus, or shares Jewish roots. State whether the project is based at or in partnership with the UCSF Mount Zion Campus, or shares Jewish roots, and describe the partnership(s), and how the project enhances care and/or health education for UCSF Mount Zion and/or the San Francisco community.
  3. Embodies one or more of MZHF’s core Jewish Values. Articulate how the project embodies one or more of MZHF’s core values.
  4. Addresses a compelling San Francisco or UCSF Mount Zion health priority. Explain the compelling San Francisco or UCSF Mount Zion health priority the project addresses, and list the specific goals (measurable outcomes) for the project numerically in order of priority. For each of the goals listed, provide a brief evaluation plan for collection of information (for example, using data from a patient survey or from metrics such as number of patients served) to facilitate MZHF’s assessment of your success in meeting project goals. To receive funding, the proposal must include a plan for evaluation with measures of both quantitative and qualitative outcomes.
  5. Potential impact of the project is significant. Describe the significant potential impact of the project.
  6. Team can successfully complete the project on time/budget. Provide a list of key project staff with qualifications, and a project timeline documenting plans to successfully complete the project on time/budget.
  7. Applicant can articulate plan for financial sustainability of project beyond the grant period. Articulate the plan for financial sustainability of the project beyond the grant period.
  8. Include the following attachments:
    1. Total proposed project budget, including line item breakdown of revenue and expenses for the
      proposed grant period and staff FTE commitments (please specifically indicate the portion of the
      budget for which funding is requested from MZHF)
    2. Current year total budget, including line item breakdown of revenue and expenses and staff FTE commitments (please specify dates of budget year submitted)
    3. List of committed, pending and proposed funders for the proposed project
    4. IRS determination verifying 501(c)(3) status (ONLY if not previously funded by MZHF)
    5. List of Board of Directors