Funding Request Form

This form is to be used by student interest groups and OMSL groups recognized by the MSC to submit their funding requests. Please email this document to no later than two weeks before your event. In addition, print out a copy for your records.

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  1. Organization name:(and a brief title for the proposal, if any)

  2. Leadership: (position, name, indiana.edu or iupui.edu e-mail on each line)
  3. Event Information Event Description
    Planned date of event (YYYY-MM-DD):
    Planned time of event:
    Location:
    Expected attendance:
    Check if you have applied for SDFC funding:
    Service-Learning: Can your project be considered service-learning according to the following definition? Service-learning is a structured learning experience that combines community service with preparation and reflection.
    yes
    Briefly describe the "learning" part of your project.

    This could be but is not limited to sharing data about the affected community with your volunteers, having your group leaders briefly present the mission and outcome of your project at an Office of Medical Service-Learning meeting, sending a survey out to your volunteers afterward with a free-response section, and more.

  4. I have read the SOG guidelines [PDF, local PDF] and understand that if my event does not meet the guidelines, it will be denied.

    Please try to seek at least partial funding for your events from other sources. We request that all funding requests be accompanied by at least one additional document (an email, letter, or other supporting document) either demonstrating partial funding by another organization or indicating that your organization has contacted other organizations for financial assistance, but has been denied / rejected. Simply indicating an attempt to obtain alternative funding is insufficient – an actual rejection / denial letter may be required. Optional supporting entities include medical departments, local hospitals / clinics, departments within the School of Medicine, or philanthropic contributions from current medical practitioners. Your event may not be funded if your organization does not perform due diligence in seeking funding from other appropriate sources.

  5. Please provide an itemized breakdown of expenses your group expects to incur in order to hold the event.
    Expense Description qty. (integer please) Cost per item Total cost (auto-filled) Cost sought for MSC funding
    $ $ $
    $ $ $
    $ $ $
    $ $ $
    $ $ $
    $ $ $
    $ $ $
    $ $ $
    $ $ $
    $ $ $
    Total: $ $
  6. Clarifications:
    • explain source/amount of any outside funding sources
    • explain numbers that do not calculate within the table exactly
    • explain expenses further if desired

Each event will require proof of attendance in order to be acknowledged by the MSC. This will aid in our record keeping and allow us to better communicate with IUPUI for funding purposes. In addition to event attendance, SIGs should begin taking membership attendance for appropriate classification in the SIG recognition and budgeting process.

Please complete this form no later than two weeks before your event. In addition, print out a copy for your records.

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MSC Treasurer