Shared Value Award ApplicationThe Mayo Clinic Shared Value Award is an annual grant that supports a new or existing collaborative effort to address a complex social challenge impacting the health and vibrancy of Olmsted County, Minn. The Shared Value Award provides up to $30,000 for a collaborative project that represents a partnership of three or more organizations and meets the following criteria:

• Helps to address an Olmsted County Minnesota Community Health Needs Assessment priority

• Includes at least one tax-exempt organization to serve as the fiscal agent

• Increases the community’s capacity to improve health and vibrancy in Olmsted County, Minn

• Uses shared goals, definitions and measurements to guide efforts and assess outcomes

Ideal projects will be championed by non-profit, business and government partners.

Deadline for submission: June 30, 2017.

Awardee announced and all applicants notified: November 30, 2017

If you need additional space to provide the requested information, please provide in an additional document and limit your materials to no more than 5 pages.

Organization InformationDate (Month DD, YYYY) Organization or Group Name 501C 3 (non-profit)?

Yes No

Organization Address (Street, City, State, ZIP Code)

Phone Number Email

Requestor Name

Our group is not a 501C 3, but we have a fiscal agent. (list)

Attach proof of tax-exempt status (IRS determination letter). Attach W-9 identification number and certification.

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Project or Program Activity Description

Amount Requested (up to $30,000) Total Cost of Project or Program

Describe how the project or program aligns with a Community Health Needs Assessment priority www.mayoclinic.org/about-mayo-clinic/commitment-to-community/community-health-needs-assessment and will use (or uses) shared goals, definitions and measurements.

Estimated Number of People Served by Project

Project or Activity Partners Name, Contact, Phone, Email

Activity’s Budget (attach here) List other funding sources or contributors to this program or activity.

How do you define success of this project or program? How will progress be measured? Attach examples of evaluation materials.

What efforts will be made to reach out to underserved or underrepresented populations? (African American, Latino, Native American, Asian, LGBTQI, veterns, disabled, economically disadvantaged)

What role will each partner assume in the project’s implementation and success?

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