Technology Hub - 2019 Participant Information and Grant Agreement Form

Please submit your form by Jan 25. Grant funds will be disbursed upon submission of this form AND the first deliverable in April. Please contact Angela Liu (, Program Coordinator at CCI, with any questions.

Organization Information

Fiscal Sponsor Information

CEO Contact 

Project Lead Contact

Project Team Members

Please list the contact information for each member of your anticipated project team, if applicable. Between the lead and team members, we recommend there be at least one clinical and one operations team member. These people will be included on call invitations and mailing lists.

Evaluation Questions

Priority Areas


Program Expectations
Grant Terms

Grant Timeline

Your $5,000 stipend will be issued after the submission of this participant form and the first deliverable, April's Pipeline Dashboard Update. Expect to receive the grant check no later than the end of May.