Grant Requests

Organization Name *Please include requesting organization's legal name.

Contact (First Name) *

Contact (Last Name) *

Contact Phone Number *(###) ###-####

Organization Phone Number *(###) ###-####

Contact's Email Address *[contact]@[website].[org or com]

Organization's Website Address http://www.[address].[org or com]

Organization's Mission *

Organization's Physical Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Title of Requested Grant *

Years of Operation *

Amount Requested *Please use numbers only.

Designation (Check all that apply) *

Non-profit (501c3 or other)Minority Owned EnterpriseDisability Owned EnterpriseWomen Owned EnterpriseVeteran Owned EnterpriseOther

Target Audience (Check all that apply) *

Adults with DisabilitiesChildren with DisabilitiesChildren / YouthDadsGrandfamiliesGrandparentsLow-income FamiliesMenMomsMoms-to-beSeniorsSeniors with DisabilitiesWomenYoung AdultsOther

Culture/Ethnicity (Check all that apply) *

African AmericanAsian (Chinese, Korean, etc.)CaucasianDisability CommunityNative Hawaiian / Pacific IslanderHispanicNative American (Native Alaskan, etc.)Other

Please choose applicable topic (select only one): *

Aging in PlaceAsthmaAutismBehavioral Health / Mental HealthCaregiver Mental Health SupportCommunity ImprovementCultural CompetencyEating DisordersEducationFinancial AssistanceFoster Care SupportFree Cell PhoneFree/Reduced Health Care: DentalHealthy Food AccessHealth & Wellness ProgramHomeless / Housing ServicesObesity (Adults or Children)Pregnancy-related SupportSmoke Free EnvironmentsSubstance Use (inc. Opioid)TransportationUtility AssistanceVeteran's ServicesWorkforce InnovationOther

If other, please describe

If Health & Wellness Program, please indicate if the program is evidence-based, evidence-informed or other *

Evidence-basedEvidence-informedOtherNot Applicable

Description of Grant *

Please provide 3-5 sentences to describe your micro-grant and the anticipated impact of the micro-grant to your organization and/or to the community

Objective #1 *

Objective #2 (if applicable) *(Please include "N/A" if not applicable.)

Objective #3 (if applicable) *(Please include "N/A" if not applicable.)

Please complete the enclosed application for grant consideration. Follow application carefully. Incomplete or inaccurate forms not accepted.

Verification

Be Committed to Your Community!

Other Items of Interest