Grant Requests

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

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.)

Verification

Please enter any two digits *Example: 12
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Be Committed to Your Community!
Other Items of Interest
- Latest Launch Event
- Statement of Commitment

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Grant Requests

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