"*" indica campos obligatorios Department/Unit:* Project Contact:* Teléfono*Correo electrónico* If Outside of YRMC:Legal Name: Website Year Founded:EIN: Mailing Address: Dirección Dirección Línea 2 Ciudad State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaSamoa AmericanaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaIslas Marianas del NorteNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Type of Organization: Mission:Vision:Contact Name: En primer lugar Última Número de teléfono:Fax Number:Board/Trustee Roster: Area Served: Requested Funding:* Total Project Budget:* Download form here.Upload Form:Max. file size: 50 MB.Please feel free to adapt the income and expense line items to fit your project. If you need to provide additional information, you may do so.Provide a detailed summary of your program/project Please include: Patient and or family/community needs that will be addressed Desired outcomes How you will measure success and report goals Population demographic served How this project/program enhances, improves the well-being of Yuma County oncology patients Define how your project/program will serve identified vulnerable or underserved populations to help address health disparitiesCite sources, statistics, and/or studies used to substantiate the need for program/project:*Is this a single year or multi-year project:* Single Multi-year Define your sustainability and how you will fund any ongoing capital or operational needs:*If this is a previously funded project/program, please explain why continued fiscal support is warranted:How will you continue this program/project if you receive partial funding:*What other funding sources have you obtained or applied for:*List the evaluation processes or methods you will use to measure progress in order to determine the degree in which you met intended output(s):*Column 1Column 2Column 3 Añadir EliminarCan you provide implemented supporting evaluation method documents, if requested?* Sí No Is this grant request to support oncology related equipment?* Sí No Δ