Contact Us - Fundación Intellectus

MD-Puerto Rico Scholarship

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Health Sponsorships Program

Formulario - Programa Auspicios en Salud (Inglés)

Contact & Organization Information

Name

Surnames

Name of requesting organization:

Physical address: *

Postal address: *

Zip Code:

City:

Country:

Phone number: *

Email: *

Institution:

Recinto de Ciencias Médicas

Universidad Central del Caribe

San Juan Bautista (School of Medicine)

Ponce Health Sciences University

Ponce Research Institute

Other Institution

Other Institution:

Activity Details

Activity name:

Activity date:

Requested amount: $ (place without special characters)

Sponsorship benefits:

0 of 800 max characters

Complete activity budget:

Maximum file size: 516MB

Sponsorship levels with descriptions:

Maximum file size: 516MB

Authorize delivery of documents:

I certify that the information contained in this application is true and I understand that none of the documents submitted will be returned to me.

Sign

Date

If you are human, leave this field blank.

Health Donations Program

Formulario - Programa Donativos en Salud (Inglés)

Organization Information

Name of the requesting organization

Start date of the organization:

Start date of the project for which you are requesting funds:

Tax exemption status

Local exemption

Federal exemption

Both

Physical address *

Postal address *

Zip Code:

City

Country

Phone number *

Email *

Is the applicant organization a unit of a larger organization?

If yes, indicate the main organization and its location.

Primary organization name

Physical Address

Postal Address

Provide a brief description of the organization that summarizes its operations.

0 of 1600 max characters

Please include historical background, mission and general goals.

Number of people impacted by your organization during the last year.

Contact Information

Principal contact of the project

Name

Surname

Title

Phone

Email

Institution:

Recinto de Ciencias Médicas

Universidad Central del Caribe

San Juan Bautista (School of Medicine)

Ponce Health Sciences University

Ponce Research Institute

Other Institution

Other Institution:

Executive director of the organization

Name & Surnames

Phone

Email

Project Information

Provide a brief description of the project for which you are requesting funds.

0 of 800 max characters

Project type

Research

Prevention in physical health

Prevention in mental health

Educational program in science or health

Travel

Other, please specify

Problem definition

Indicate the problem that seeks to be solved in this project.

0 of 800 max characters

Indicate the total number of people affected by this problem in the geographic area you seek to impact.

0 of 400 max characters

Mention the causes that are identified as generating this problem.

0 of 1600 max characters

Indicate how this project contributes to the possible solution of this problem.

0 of 1600 max characters

Explain the impact you want to achieve with this project.

0 of 1600 max characters

Mention other organizations currently working towards similar solutions and what they are doing.

0 of 800 max characters

Expected results

What are the main objectives of the project? How long do you expect to achieve them?

Goal

0 of 3200 max characters

Budget Information

Total Project Budget

$

Total budget of the organization for the current year.

$

Breakdown of expenses for the requested amount.

Maximum file size: 516MB

Detail other sources that you will use to complete the budget needed, in addition to the contribution you are requesting from the Fundación Intellectus. (place the amount without special characters)

Institution

Input

$

Total

Results measurement

Explain what methods will be used to measure project results and how project success will be defined.

0 of 2000 max characters

Authorize delivery of documents

I certify that the information contained in this application is true and I understand that none of the documents submitted will be returned to me.

Sign

Date

If you are human, leave this field blank.

MD-PHSU Scholarship

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Science Camp Scholarship

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MCAT Test Scholarship

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SCHOLARSHIP MD-PHSU

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SEXUAL VIOLENCE RESEARCH SCHOLARSHIP

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Health Research

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MD-Community Scholarship

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Address

Phone Number

Hours

Email

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