Chapter Grant Application

Required IconRequired Form Items

Project Coordinator Information

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

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.)

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

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

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.

(Please estimate financial support in dollars and member time in hours)

Approval Signatures & Email Addresses

Required IconSignature of Project Coordinator

Required IconSignature of Chapter President

Required IconSignature of Chapter Executive Director

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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