2023 IMPACT Grant Program
Application Form

Step 1: Review the qualifications and requirements document.

Step 2: Fill out form below and upload all required supporting materials.

Application Deadline: October 16, 2023

Applicant Information

Name of applicant: *

AAPA ID: * 🛈

Applicant status: *

PA

PA Student

Applicant street address: *

Address line 2:

City: *

State: *

Zip code: *

E-mail address: *

Phone number: *

If applicant is a student, name of faculty sponsor: *

PA program: *

Sponsoring Organization Information

The sponsoring organization is the organization that will receive/manage grant funding if selected as a grantee. Grant funds are disbursed to this organization rather than to the individual applicant. It must be a nonprofit organization (PA program, constituent organization, or other organization with nonprofit status).

Sponsoring organization name: *

Is this the organization that will receive/manage grant funding (if awarded)? *

Yes

No

If no, please indicate the name of the organization that will receive/manage grant funds.

Name and title of main contact at sponsoring organization: *

Sponsoring organization address (mailing address): *

Address line 2:

City: *

State: *

Zip code: *

E-mail address (main contact): *

Phone number: *

Sponsoring organization status: *

PA program

Constituent organization

Other nonprofit organization

Is this organization incorporated? *

Yes

No

Is this organization a nonprofit? (must be a nonprofit in order to meet eligibility criteria) *

Yes

No

Based on the response above, this organization is not eligible to serve as the sponsoring organization for this grant application. Sponsoring organizations must be nonprofit organizations.

Project Information

Name of project: *

Project location (must be city/state within the U.S. or its territories): * 🛈

Brief description of project (250 word maximum): *

0/250 words

Funding requested: *

Total project budget: *

If selected as a grantee, check should be made payable to (sponsoring organization name): *

Required Documents

Attach detailed project budget. *

Attach written proposal (maximum 6 pages) addressing the items/questions included in the qualifications and requirements document (see item #3 under "Application Requirements"). * 🛈

Attach letter of support signed by an official of the sponsoring organization that includes all requested components as outlined in the qualifications and requirements document (see item #4 under "Application Requirements"). * 🛈

Attestations

Applicant Attestations

Please review and indicate your agreement with the following statements by checking the box next to each. *

I attest that the contents of this grant application are true and accurate. I agree that if awarded a grant, information about this project and my photograph may be published in AAPA and PA Foundation publications and news releases.

I attest that the individuals and organizations applying for this grant do not advocate, support, or engage in discrimination in the provision of health care on the basis of age, color, disability, ethnicity, gender identity or expression, national origin, union membership, political affiliation, race, size, religious affiliation, sex, sexual orientation, or socioeconomic or veteran status.

Digital signature of applicant: *

clear

Date: * +

Sponsoring Organization Attestations
To be signed by main contact at sponsoring organization. If the individual applicant is affiliated with the sponsoring organization, form should be signed by the applicant's supervisor; if no supervisor, applicant may sign it.

>> View/download sponsoring organization attestation form

Upload signed sponsoring organization attestation form.

Faculty Sponsor Attestations

To be completed only if applicant is a PA student.

>> View/download faculty sponsor attestation form

Upload signed faculty sponsor attestation form.

Additional Questions

The PA Foundation would like to know more about the individuals applying to our programs. Please provide the following information if you are comfortable doing so, or select “Prefer not to respond.” This information will not be used in the grant selection process.

Do you identify as a sexual or gender minority*? *

Yes

No

Prefer not to respond

*From the National Institutes of Health: Sexual and gender minority (SGM) populations include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex. Individuals with same-sex or -gender attractions or behaviors and those with a difference in sex development are also included. These populations also encompass those who do not self-identify with one of these terms but whose sexual orientation, gender identity or expression, or reproductive development is characterized by non-binary constructs of sexual orientation, gender, and/or sex.

Race/ethnicity (select all that apply): *

Career stage: *

Thank you for completing this application!