Non Profit Sponsorship Application by etu20787

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									                 KAISER PERMANENTE
                   EAST BAY AREA
          2010 COMMUNITY BENEFIT ACTIVITIES &
         SPONSORSHIP APPLICATION & GUIDELINES

In 1945, Henry Kaiser and Dr. Sidney Garfield formed a partnership to provide comprehensive health care
to workers, families, and the general public. This marked the beginning of Kaiser Permanente and the
start of a whole new way to deliver health care. It also marked the beginning of Kaiser Permanente as a
nonprofit institution in the community.

Since its inception, the mission of Kaiser Permanente has included the belief that healthy stable
communities benefit everyone. We at Kaiser Permanente believe that we are responsible not only for the
health of our members but also for the communities that surround us.

How does Kaiser Permanente help build healthy communities? By listening to and working with local
agencies, nonprofit organizations, and community groups to identify areas that promote good health and
strengthen our communities.

All people deserve to lead healthy lives and be treated with compassion and respect. Kaiser Permanente
will continue to dedicate itself to this principle for the benefit of our members and our communities.


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COMMUNITY BENEFIT SPONSORSHIPS AND DONATIONS
The East Bay Area prides itself on its commitment to the community it serves. Opportunities exist for
organizations to apply for financial sponsorship of community-based activities. The East Bay Area
encompasses the cities in Northern Alameda and West Contra Costa counties.

Throughout the year East Bay Area physicians and employees participate in a myriad of community service
initiatives that promote healthy activities and living. Participation in these events affords Kaiser Permanente
the opportunity to live out its mission of making lives better.

Requests for support for community activities such as health fairs, dinners, health education forums,
conferences, and/or symposiums up to $5,000 may be submitted throughout the year on an ongoing basis
through October 31, 2010. A summary of the event/activity is to be submitted after the event/activity has
taken place for evaluation.
Funding (up to $5,000) for capacity building (e.g. technical assistance, training, board development, planning)
may be provided in lieu of event sponsorship.

All requests must be submitted in writing by using the attached Community Benefit Activities and Sponsorship
Application. Requests must be submitted at least 45 days prior to the event.

SUBMISSION REQUIREMENTS
When submitting a grant request to the East Bay Area Public Affairs Department, please ensure that the
application contains the following documentation:
      Cover Letter on your organization’s letterhead, or the letterhead of your fiscal agent
      Copy of current IRS determination letter indicating 501(c)(3) tax-exempt status.
      Detailed project budget showing other sources of funding and the amount requested of Kaiser
       Permanente.
      List of Board Members including name, title, and geographic area of residence.
      An electronic version and one hard copy of the application are required.
      Faith-Based organizations: We will only accept applications for monetary funding from inter-faith
       collaboratives of 3 or more churches that are providing services to the general public.
           o   Fiscal Sponsorship required: A community non profit partner with an eligible 501c3 IRS status
               can apply for funding as a fiscal sponsor on behalf of the inter-faith collaborative.
           o   Letter of intent: An additional letter is required from faith organizations demonstrating that the
               services being provided are/will be made available to the broader public. Please include a brief
               description of how you will track the number of non-affiliated community members served
               through this project.

ELIGIBILITY REQUIREMENTS
Requests will be considered if the project/organization requesting support meets the eligibility criteria and, at a
minimum, two of the following:
        The organization addresses at least one of the East Bay Area’s identified Community Health
         Priorities:
                  Healthy Eating and Active Living
                  Childhood Asthma
                  Prevention of Violence
                  Mental Illness and Substance Abuse

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                  Prevention of Sexually Transmitted Diseases and Improvements in Sexual Health

        Only nonprofit or public benefit organizations are eligible to receive funding. Unincorporated groups
         or agencies can make arrangements to utilize an eligible nonprofit organization as a fiscal sponsor
        Funds must be used to serve vulnerable populations of Kaiser Permanente’s East Bay Area (e.g.
         low-income, underserved, ethnic/minority populations)
        Projects must address needs in the areas of health and human services
        The mission and values of the organization confirm the mission and values of Kaiser Permanente
        Strategies must be consistent with our values and established Community Health Priorities
        Funds must be spent by December 31, 2010
        A summary evaluation of the event/activity is required. Depending on the date of the activity this
         summary is due July 31st or December 31st.

PROCESSING GUIDELINES
       All applicants will receive notification that their application has been received within 1 – 2 weeks.

       It may take up to 4 weeks to issue an approval or declination notice. Incomplete applications could
       delay the review process.

       If approved, it may take 4 – 6 weeks for funding to be issued. Please submit your requests early with
       the required documents. Your request may take 6 – 12 weeks to complete processing.

FUNDING LIMITATIONS
Kaiser Permanente’s East Bay Area Public Affairs Department will not consider funding requests from the
following types of organizations or for the following activities/purposes:
       Political campaigns*
       Contributions to endowments or memorials
       Emergency loans
       Youth sports leagues
       Field trips
       Religious purposes**
       Individuals and/or personal requests such as scholarships, individual tuition, payment for educational
       purposes, conferences, etc.
*As a nonprofit organization, Kaiser Permanente is legally prohibited from funding political campaigns.

** Kaiser Permanente may fund faith organizations providing secular programs that serve the greater
community and are consistent with our Community Health Priorities. These organizations must apply
under a fiscal sponsor.



Please call 510-752-6122 if you have any questions.




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KAISER PERMANENTE
EAST BAY AREA - COMMUNITY BENEFIT SPONSORSHIP PROGRAM
2010 EVENT/SPONSORSHIP APPLICATION
The requested information may be entered on this form or submitted on your organization’s letterhead. If
submitted on this form, please include a cover letter on your organization’s letterhead.

I. CONTACT INFORMATION
Agency Name
Street Address
(No PO Boxes unless
location is confidential).
City, ST, ZIP Code
Phone/Fax
Email (required)
Web site
Contact Person/Title
Executive Director

Fiscal Agent
(if any)
Contact Person/Title
Phone/Fax/Email
Tax Status                                501(c)3                    Public Entity
Tax ID Number

II. ORGANIZATION INFORMATION
Brief summary of organization’s history, mission, and goals




Description of current programs, activities, and accomplishments




III. EVENT INFORMATION
Event title:
Location:


Event period:                                                 Total amount requested:



Dinner and Luncheon events: Please include the amount of donation benefiting your organization
(Total amount requested minus cost of meal or services provided to Kaiser Permanente):

For example: $1,000 Sponsorship – (10 meals at $20) = $1,000 – $200 = $800 solely benefiting your
organization



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Total event budget:
Geographic area(s) to be served:
Community partners:
Kaiser Permanente groups/individuals involved:


Prior funding received from Kaiser Permanente (list below):

Date:                     Amount:                              Project/Event:


Date:                     Amount:                              Project/Event:


Date:                     Amount:                              Project/Event:



IV. COMMUNITY HEALTH PRIORITY

             Healthy Eating and Active Living

             Childhood Asthma

             Prevention Violence

             Mental Illness and Substance Abuse

             Prevention of Sexually Transmitted Diseases and Sexual Health


V. GRANT PURPOSE
Event/Project description:




Please answer the following questions -

    1. What are the goals and objectives for the event/project?

    2. Who is your target audience?

    3. Describe the target population that will benefit from this effort. Please include age group,
       race/ethnicity, gender served and # of clients impacted.


Plans to accomplish the goals, objectives, and timeline for implementation.




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Description of how Kaiser Permanente funding will be used.




VII. PROJECT BUDGET

 List all           Provide a brief         List the amount    List and name      List any in-kind
 operating       description of budget      of funding being   other sources      donations, the
 expenses                 item                requested of     of secured         source and
                                                 Kaiser        funding for this   estimated value
                                              Permanente       project




 Total:




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VII. COMMUNICATIONS
Description of promotional and outreach activities.




VIII. EVALUATION PLANS
Description of how the success of this event will be defined and measured. Provide a brief summary of how
the outcomes of the event will be communicated and to whom.




AGREEMENT/SIGNATURE

Your signature below confirms your agreement to complete a summary of your activity/event by July 31, 2010 or
             st
December 31 , 2010 (if your event/project is after July) and you have read and meet the eligibility criteria.


Name/Title (please print)


Authorized Signature & Date


Please submit completed application materials to:

                                              Glenda Monterroza
                                       Kaiser Permanente East Bay Area
                                           Public Affairs Department
                                                             nd
                                           4501 Broadway, 2 Floor
                                              Oakland, CA 94611

                                       510-752-6122, FAX 510-752-1515

                                 Public-Affairs-Community-Benefits@kp.org




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