2021 Memorial Medical Center Application

*All items with an asterisk are required.

All items in bold must be completed with the provided information for SIUSOM applicants.

(Mark box after reading the MMCF policies and procedures.)

[ ] I acknowledge that I have read and understood the above policies and procedures in its entirety and agree to abide by them.*

Applicant Information

*Name

First Name:

Last Name:

Credentials/License:

*Phone Number:

*Title and Department:

*Mailing Address:

*City:

*State (select):

*Zip:

*Name of Organization: SIU School of Medicine

*Email Address:

*Are you part of MHS? No

*Are you a non-profit community organization? No

Project Information

*Title of Project:

*Type of Project: Select from- Patient Care, Research Education

Grant Administration Information

*Is the main contact different than the name provided in Applicant Information?

YES

First Name: Grants

Last Name: Office

Title: Grants Office

Phone Number: 217-545-4549

Email: grants@siumed.edu

*Is the budget contact different than the name provided in Applicant Information?

YES

First Name: Grants

Last Name: Office

Title: Grants Office

Phone Number: 217-545-4549

Email: grants@siumed.edu

*Is the award contact different than the name provided in Applicant Information?

NO

Project Executive Summary and Narrative:

*Please provide a brief executive summary and how MMCF funds will be used in project?

Limit to 100 words.

*Have you applied to the Foundation for this project in the past?

YES/NO

*Please upload a more detailed project narrative.

Select YES to upload; Select NO to continue without a detailed narrative.

If you wish to upload a Project Narrative, it is limited to 3 pages and the following must be included in laymen’s terms:

Objective

Expected Outcomes

Anticipated Timelines

Impact on patient care, education, and/or research in support of Memorial’s mission to improve the health of the people and communities Memorial services.

Project Budget

Please use the Excel Budget Template first before completing the budget portion of the application.

The Grants Office will review and approve your budget, and then it can be entered.

You will also need to complete a Word Budget justification to describe personnel and costs.

If applicable, you may need to submit a Waiver Request for Voluntary Cost Sharing if in-kind support is requested.

These documents must be submitted to grants@siumed.edu by 8:00AM on February 15, 2021.

*What is the total amount requested from Memorial Medical Center Foundation?

*Is this project viable with partial funding?

YES/NO

*If YES, please explain:

*Which of the following items did you list in the budget table above?

(Select all that apply)

*Upload budget justification.

*Do you have in-kind support to report?

YES/NO

*If Yes, upload Waiver Request for Voluntary Cost Sharing.

*Do you have additional conference revenues, sponsorships, or grants to report?

YES/NO

*Are you a MHS VP, University Grant or Contract Office or Non-Profit Executive Director?

NO

*Please enter the email of the Organization’s MHS VP, University Grants and Contracts Office or Non-Profit Executive Director.

grants@siumed.edu

Send the Request Now

Do not submit the grant until given prior approval to do so from the Office of Grants and Contracts.