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Chapter Grant Application

*Required

Project Coordinator Information

Regular Grants
Explanation of project objectives, what it will accomplish, how it will benefit emergency medicine and advance ACEP’s Mission Statement and Values and/or Priority Objectives, or chapter goal(s), and how it could be used by other chapters

Development Grants
Detailed description of the project for which the chapter is seeking an ACEP chapter grant (purpose of project, what it will accomplish, how it will benefit emergency medicine, etc.)

Project Work Schedule
(Please list project tasks, individuals responsible, and projected dates of completion)

Proposed Marketing Plan (if applicable)

Total Project Budget
(Include a line item budget for total project costs and revenues)

Amount of Funds Requested from the ACEP Chapter Grant Program

Requested Funding Schedule
Percentages of total grant request needed for project start up and throughout the duration. This schedule must be tied to the project work schedule, and will be used by Chapter Services to set grant payments, if funding is awarded. If start-up funds will be needed, they must be specifically requested in this block of the full grant proposal.

Chapter Support to Project - both financial and member time
(Please estimate financial support in dollars and member time in hours)

Approval Signatures & Email Addresses

By affixing my electronic signature to this form, I hereby attest that I have obtained all necessary approvals (Chapter President, Chapter Executive Director, and Project Coordinator) and have authority to submit this application on behalf of the Chapter.

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