Request for Funding

The Women’s Board is organized exclusively to further the charitable and educational purposes of the Hospital, its constituents, and the local community in the areas of health care, education, health care advancement initiatives, patient advocacy, health care awareness promotion, and medical research. Please provide comprehensive and detailed information to request support from the Women’s Board.

To request support from the Women’s Board, please complete the form below. For additional inquiries or questions, you may call 571-357-8902 or email

Submission deadline is 5pm on September 30, 2019.

Name *
What is the impact of this project? Who are the population(s) served? What is your proposed timeline? How will the impact be measured and reported to the Women's Board?
Specifically how will these funds be used? What other sources of funding do you have or are you seeking from others? Please provide an itemized budget for your funding request.
If you could move forward with partial funding, please explain how this is possible and the amounts needed.
I understand that I (or representative) must give an update on the progress of the project when prompted by the Women's Board. *
I understand I must acknowledge the Women's Board when communicating about the project with internal or external audiences. *
I understand I must be proactive in inviting the Women's Board to participate in engagement opportunities, when appropriate. *
I understand I must inform the Women's Board of any change in project plans or budget. *