COVER PAGE
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Name and address of applicant organization
Name and title of the organization’s chief executive
Name and title of primary contact with email address with phone number.
Title of proposed program.
Total program budget.
Amount requested.
Fiscal year ending: month/year.
Beginning and end dates of the program covered by this grant request (month/day/year)
Brief summary of program (40 words). This should describe your proposed program succinctly in
a useful “sound bite.”
10. Federal Tax ID number of the 501(c)(3) agency with fiduciary responsibility
11. Indicate the grade(s) and the number of youth you plan to enroll in your program?
Grade(s)
# of Youth
Where will the program take place:
List towns the youth reside:
Total
 Schools
Agency-based
 Both
12. On average, how many youth will attend the program each day?
Plan____
13. TOTAL number of DAYS the program will be open?
Plan____
14. How many youth will attend at least 50% of the days the program is open?
Plan____
15. TOTAL number of WEEKS the program will operate in the upcoming school-year? Plan____
16. How many staff will be dedicated to the program?
Plan: _ _FT __PT
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Signature of executive director, president, CEO, or board chair
___________
Date