Dental Materials and Supplies Grant

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.
Approval from CDA Foundation staff is required prior to accepting e-mailed proposals. 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

Indicate program type:

New Program Expansion Program Innovative Program

Name of Requesting Organization Web Site Address

Mailing Address Street Street (cont.) City State Zip

Shipping Address (if different than mailing address above) Street Street (cont.) City State Zip

Telephone Fax E-mail Address

Project Contact's Name First Name Last Name

Project Contact's Title

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

Project Contact's E-mail Project Contact's Phone

Executive Director/President's Name First Name Last Name

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

A licensed medical professional must screen the shipment. Please provide contact information for a dentist or other licensed healthcare professional that will be responsible for screening the donated product. First Name Last Name

Licensed Medical Professional's Title License # Licensed Medical Professional's E-mail Licensed Medical Professional's Fax Licensed Medical Professional's Telephone Organization's 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

Tax exempt, 501(c)(3) (Please enter Fed. Tax ID# below) Government Tax Exempt Unit Other (Please specify)

Fiscal Sponsor

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

Fiscal Sponsor's Name First Name Last Name

Fiscal Sponsor's Title Fiscal Sponsor's Telephone

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

Fiscal Sponsor's Fed. Tax ID#

Please upload your 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. Organizational Services

Summary of Services Provided

Maximum 750 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) to be served

African American

Latino

Native American

Asian (Specify):

Other (Specify):

All races

Population (e.g., Children, Elderly, Migrant Workers, etc.): Age Groups

Region:

Urban Rural

Number of dental patients to be served annually:

V. Organization Information

Organization Operating Budget (Total Expenses):

Current Year Prior Year

Please upload your tax return (Form 990) here:

Upload File:

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

Number of dental professionals currently employed in each of the following categories:

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

VI. Proposal Outline

1. Describe the need for your request.

Maximum 1,000 characters. Characters used: 0.

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

Maximum 2,200 characters. Characters used: 0.

3. How will the supplies from this grant program enhance or expand your organization's ability to provide services (expected outcomes)?

Maximum 1,000 characters. Characters used: 0.

4. How do you plan to sustain these services?

Maximum 1,200 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. Please indicate the materials and supplies you need most for ALL the clinics you represent by checking as many as needed below:

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

Please upload your letter of support here.

Upload File:

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

IX. Required Donation Agreement and Affidavit of Purpose

1. HSI Donation Agreement:

Please download the HSI Donation Agreement, scan completed agreement and upload it in the file below.

Download the HSI Donation Agreement

Please upload your completed HSI Donation Agreement here.

Upload File:

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

2. Affidavit of Purpose:

Please download the Affidavit of Purpose, complete and upload it in the file below.

Download the Affidavit of Purpose

Please upload your completed Affidavit of Purpose here.

Upload File:

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

X. Certification

I acknowledge that the decisions of the CDA Foundation and Henry Schein, Inc., 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 and Henry Schein, Inc., 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 and Henry Schein, Inc., 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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Dental Materials and Supplies Grant

I. Organization Information

II. Requesting Organization Tax Status

Fiscal Sponsor

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

III. Organizational Services

IV. Project Target Population

V. Organization Information

Organization Operating Budget (Total Expenses):

Please upload your tax return (Form 990) here:

Number of dental professionals currently employed in each of the following categories:

VI. Proposal Outline

Budget Form

Please upload completed budget form here:

VII. Please indicate the materials and supplies you need most for ALL the clinics you represent by checking as many as needed below:

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

Please upload your letter of support here.

IX. Required Donation Agreement and Affidavit of Purpose

1. HSI Donation Agreement:

Please upload your completed HSI Donation Agreement here.

2. Affidavit of Purpose:

Please upload your completed Affidavit of Purpose here.

X. Certification

Electronic Signature (Required)

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