Return to Home Page CHURCH HOME SOCIETY
Return to Self-Screening Page GRANT REQUEST FORM
Please Select All this text and copy it into a New Blank Document, fill it out on your computer and send it by email to our administrator (firstname.lastname@example.org) along with all requested attachments.
1. Name and address of the program. (Programs are restricted to Massachusetts east of Worcester County)
2. If applicable, name, address and website of the fiscal agent 501(c)(3) organization that will receive funds for your program (Please attach a copy of the relevant IRS 501(c)(3) form to this grant request.)
3. Contact person for the program including email and phone
4. Site visit street address
5. What is the dollar mount of your request? What is the projected annual budget for your program? (Please attach budget sheet)
6. If applicable, what is the projected annual budget of your fiscal agent organization? (Please attach budget sheet)
7. What line item in your program budget will the Church Home Society grant monies support?
8. What are your current and prospective funding sources not only for your program but also for your fiscal agent institution?
9. What are the ages of the youth your program will serve? In what ways are the youth currently underserved (ex: what are their economic, cultural, educational or spiritual needs)?
10. How many youth does this program support? How many in the wider community?
11. If this program is not a new program, what year did this program begin?
12. Please describe the overall nature of your need. Is it
…to start up a new initiative?________
…to stabilize a program started in the last three years?_______
…to expand a tested program to new locations?_______ If Yes, where ?________________
…to help an existing program get back on its feet?________
13. Over what length of time will the youth be in the program? How often will the youth meet? (sample answer: three months, October thru Dec, meeting weekly from 6 to 8 on Wednesdays)
14. Does your program (check all that apply):
Involve young persons in the planning and/or execution of the program? _____
Encourage initiatives which empower youth, cultivate skills, and encourage healthy living? _____
Equip youth with Leadership Training? _____
Promote, in their aim and execution, goals that are compatible with the Christian view of life
and society, which values all creation as the work of God and seeks reconciliation and love
among human beings?_____
Provide service-oriented or community building efforts, e.g.
paid or volunteer group projects for youth, especially during the summer? _____
youth projects providing assistance to the elderly, handicapped, etc.? _____
youth environmental projects, such as education or cleanup? _____
vocational assistance such as job counseling and employment of youth?____
group volunteer opportunities? ______
Other (please explain)_______
15. Please summarize the program goals and the program structure you have designed to meet those goals. *Please limit your response to no more than two pages.*
16. How will you measure success? *Please limit your response to no more than one page.*
Please attach the following to complete your grant Request:
-Accountability Persons: As applicable, names of the Board of Trustees, Advisory Board,
Church Governance Board, Pastor(s)
-Copy of the applicable 501(c)(3) form
If you have any questions, please email or call our administrator, Mrs. Roberta Tripp,
at email@example.com or 1-617-482-5328