Application Deadline: March 31, 2024

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

  • 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:

  • Amount Requested
  • Matching Funds from Agency
  • Total Cost
  • Other:

  • Amount Requested
  • Matching Funds from Agency
  • Total Cost
  • Total:

  • Amount Requested
  • Matching Funds from Agency
  • Total Cost

  • III. Agency Information

  • AGENCY RESPONSE INFORMATION

  • DEMOGRAPHIC INFORMATION

  • PERSONNEL

  • IV. Budget

  • 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.
  • 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.