SJC Application

Demo Application

Organization Name
EIN
Organization Annual Budget
Address
City
State
Zip Code
Phone
Email
Website URL
Contact Person Name
Contact Person Phone
Contact Person Email
Program Name
Program Requested Amount
Program Budget
In which Kaiser Permanente service area will this serve?
When will the project start and end?
Provide a 1 to 2 sentence snapshot of the project.
Briefly describe the population and location who you will serve?
Is this project intended to benefit a specific racial or ethnic group?
What are the activities for the first objective of the project?
Board of Directors
What are the outcomes for the first objective of the project?
How many unique individuals will be served by this funding?