CDA Foundation Grant Application

Thank you for expressing interest in the CDA Foundation and its grant giving program. We appreciate you applying for our services which are available to benefit people who want to improve the oral health of all Californians.

Prior to beginning the online application process, please scan the following supporting documents and have them ready to upload as attachments (Word, Excel, PDF, etc.) to this application when prompted to do so later:

Most recent tax return (Form 990);
Tax exempt IRS determination letter or tax exemption verification, or letter of agreement signed by an eligible fiscal sponsor; and
Letter of support from a dental health professional or organization.

During this application process, you will need to answer the questions by typing text, checking boxes/buttons, and where prompted, upload/download documents as attachments to this online application. All requested file uploads and downloads are required to complete your application. Once we have received your application, an automated receipt confirmation will be sent to you at the PROJECT CONTACT E-MAIL address provided below. Good luck!

Submission Criteria

Complete online application, attaching all supporting documents, and submit online.
No mailed or faxed applications will be accepted. If you are experiencing difficulties submitting the online application, please contact the CDA Foundation staff via e-mail at jolene.murray@cda.org to request an alternative submission method and a Word document of the grant application will be sent to you for completion.

Incomplete applications are ineligible to receive an award.

Light Purple Shaded Areas are Required Fields

I. Organization Information

Name of Requesting Organization Web Site Address

Mailing Address Street Street (cont.) City State Zip

Telephone Fax E-mail Address

Project Director's Name Who is Responsible for Implementation of this Project

Title First Name Last Name Suffix

Project Director's Title

Project Director's Address (If different than mailing address above) Street Street (cont.) City State Zip

Project Director's E-mail Project Director's Telephone

Executive Director / President's Name

Title First Name Last Name Suffix

Executive Director/President's Telephone Executive Director / President's E-mail Mission Statement

Maximum 500 characters. Characters used: 0.

Is your organization:

FQHC HPSA/DHPSA

What percentage of your patients are MediCal and/or Healthy Families eligible?

II. Requesting Organization Tax Status

II. Requesting Organization Tax Status

Tax exempt, 501(c)(3) (Please enter Fed. Tax ID# below) Governmental tax exempt unit Other (Please specify)

Fed. Tax ID # (If Tax Exempt)

Fiscal Sponsor

If your organization is not a 501(c)(3) or government tax exempt unit, please ID your fiscal sponsor.

Fiscal Sponsor's Name

Fiscal Sponsor's Contact Name

Title First Name Last Name Suffix

Fiscal Sponsor's Telephone

Fiscal Sponsor's Address Street Street (cont.) City State Zip

Fiscal Sponsor Fed. Tax ID (required if you have a fiscal sponsor)

Please upload IRS determination or tax exemption verification, or letter of agreement signed by an eligible fiscal sponsor here:

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

III. Project Description

Project Title Project Summary

Maximum 700 characters. Characters used: 0.

Primary Project Classification

Preventive care Consumer Education Restorative Care Fluoridation Other

Statewide

Yes No

If no, then list the county(ies) where the project will be implemented (List all that apply):

IV. Project Target Population

Primary ethnicity(ies) of target population (check as many as needed)

All races (or)

African American

Latino

Native American

Asian (Please specify)

Other (Please specify)

Population (e.g. Children, elderly, migrant workers, etc.) Age groups

Region

Urban Rural

Number of dental patients to be served annually

V. Organization Information

Financial Grant

Amount Requested Total Project Budget Project Time Table (From) Project Time Table (To)

Organization Operating Budget (Total expenses)

Current Year Prior Year

Please upload tax return (Form 990) here:

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

What percentage of your budget or dollar amount is allocated for purchasing dental supplies and materials?

VI. Proposal Outline

Describe the need for your project:

Maximum 1,000 characters. Characters used: 0.

How will your project address these needs (objectives & planned activities)?

Maximum 4,000 characters. Characters used: 0.

What do you expect to accomplish at the conclusion of the project (expected outcomes)?

Maximum 1,000 characters. Characters used: 0.

List project collaborators and their role in the project.

Maximum 1,200 characters. Characters used: 0.

How do you plan to sustain this project?

Maximum 1,200 characters. Characters used: 0.

What are the greatest challenges for this project?

Maximum 1,000 characters. Characters used: 0.

Is this project scalable in case the CDA Foundation cannot provide the full amount of funding requested?

Maximum 600 characters. Characters used: 0.

Budget Form

Identify the resources necessary to implement the project. (Download and fill in budget template provided below to identify revenue sources, program expenses, salary/personnel costs and indirect costs).

Download the Budget Template

Please upload completed budget form here:

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

VII. Letter of Support From a Dental Health Professional or Organization

Please upload letter of support here:

Upload File:

Please keep individual attachments under 300k. Please click here for scanning tips.

VIII. Certification

I acknowledge that the decisions of the CDA Foundation are final and that this is a competitive selection process. I certify that the information provided is complete and accurate to the best of my knowledge. I understand that this application may be denied or withdrawn if it is incomplete and/or if any information reported is found to be intentionally misleading, inaccurate or fraudulent.

I authorize the CDA Foundation to use my name and/or photo for the purpose of community and public relations.

Electronic Signature (Required)

Please check the electronic signature button, type in your first and last name in the space provided, and click the button on this page labeled "Submit" to certify that all statements made in this application and its attachments are complete and accurate to the best of your knowledge, and to authorize the CDA Foundation to verify the information provided in this application and its attachments.

Electronic Signature (Type full name):

By submitting your application, you certify that all statements made in this application and its attachments are complete and accurate, and you understand that falsification will disqualify your application.

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CDA Foundation Grant Application

Submission Criteria

I. Organization Information

II. Requesting Organization Tax Status

Fiscal Sponsor

Please upload IRS determination or tax exemption verification, or letter of agreement signed by an eligible fiscal sponsor here:

III. Project Description

IV. Project Target Population

V. Organization Information

Financial Grant

Organization Operating Budget (Total expenses)

Please upload tax return (Form 990) here:

VI. Proposal Outline

Budget Form

Please upload completed budget form here:

VII. Letter of Support From a Dental Health Professional or Organization

Please upload letter of support here:

VIII. Certification

Electronic Signature (Required)

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