EMS Equipment Grant Application

Application Deadline: Closed

Please complete and submit the form below before the application deadline. You may also download the application and email it to Kim Duncan Martin, Executive Director, at kim@mediconefoundation.org.

I. Agency Contact
Applicant Agency:
Contact Person:*
Title:
Address
Street Address City State ZIP Code
Phone:*
Fax:
Email:*
II. Funding Request

Funding will be on a matching basis. The Medic One Foundation may contribute up to 75% of the cost of the requested equipment.

(Please list only the total amount of requested funds by category on this page. If you are requesting a grant for more than one item, please include an itemized list of your funding request in section IV. Requests for equipment costing $1,000 or more must include two vendor bids verifying the cost.)
Medical Equipment:
Medical Equipment - Amount Requested:

Amount Requested
Medical Equipment - Matching Funds from Agency:

Matching Funds from Agency
Medical Equipment - Total Cost:

Total Cost
Other:
Other - Amount Requested:

Amount Requested
Other - Matching Funds from Agency:

Matching Funds from Agency
Other - Total Cost:

Total Cost
Total:
TOTAL - Amount Requested:

Amount Requested
TOTAL - Matching Funds from Agency:

Matching Funds from Agency
TOTAL - Total Cost:

Total Cost
Equipment Item Requested:
Describe the need and how the funds will enhance the delivery of emergency medical services.
Why is this funding needed at this time? What will happen if you do not receive the funding?
Why are you not including this purchase within your regular operations or capital budget?
If your request is funded, how will you acknowledge or recognize the Medic One Foundation?
Please indicate the total dollar amount of charitable gifts your agency received in the last fiscal or calendar year.
III. Agency Information
Name and number of Fire Protection District/Department:
Name of Chief:
Mailing Address:
Phone:
Fax:
Email:
AGENCY RESPONSE INFORMATION
For most recent year of:
Total # of responses:
Total # of EMS responses:
Percent EMS aid responses:
Number of ALS responding units:
Number of BLS responding units:
DEMOGRAPHIC INFORMATION
Square miles in service area:
Population served:
Special areas or miles in service area:
PERSONNEL
Number of full-time personnel:
EMTs:
Paramedics:
Number of volunteers:
Number of volunteers EMTs:
IV. Budget
Please identify the source of matching funds.
EMS Budget for current year of:
Dollar Amount:
Do you have a depreciation funding plan for the requested equipment?:
- Yes
- No
Total Fire Department Operating Budget:
If you are requesting a grant for more than one item, please provide a detailed listing of your funding request, along with individual costs:
For items costing $1,000 or more, please upload vendor bid(s) here: BID ONE
Accepted file types: doc, pdf, txt, gif, jpg, jpeg, png, Max. file size: 21 MB.
Acceptable file types: doc,pdf,txt,gif,jpg,jpeg,png.
For items costing $1,000 or more, please upload vendor bid(s) here: BID TWO
Accepted file types: doc, pdf, txt, gif, jpg, jpeg, png, Max. file size: 21 MB.
Acceptable file types: doc,pdf,txt,gif,jpg,jpeg,png.

EMS Equipment Grant Application

Application Deadline: Closed

I. Agency Contact

II. Funding Request

III. Agency Information

IV. Budget

Your gift will be matched dollar for dollar!

Your gift will be matched
dollar for dollar!