THE DOUTY FOUNDATION

P. O. Box 1437 * Philadelphia, PA 19105 *

  1. Name of Organization: ______

(and fiscal agent, if applicable)

  1. Contact Person and Title: ______Email: ______
  1. Address: ______City: ______State: ____Zip:______
  1. Phone: ______Website: ______
  1. Type of Request from The Douty Foundation: General Operating or Project

Project Name, if applicable:

  1. Total Funding Request Amount:
  1. Previous Douty Foundation funding:O YesO No

If yes, please indicate date & amount received from foundation over the past 6 years:

Date: ______Amount Received: ______

Date: ______Amount Received: ______

  1. Focus of Grant Application: (Although this request may reflect more than one area, please check the one thatrepresents the major focus of this request)

O Education O Community Development O Art Education O Youth ProgramsO Social Services

  1. Geographic area served by current grant request:

O Montgomery County O Philadelphia

  1. Client population served by grant request (check as many as apply):

O Child/Youth (ages 0 – 12)O Young Adults (ages 13 – 21)

O Adults (ages 22 – 69)O Older Adults (age 70+)

  1. Total annual organization budget: $ 12. Project budget (if applicable): $
  1. Please check all that apply to your organization:

Demonstrated inclusion of underserved, unheard or unempowered communities
Demonstrated commitment to community engagement, education and grassroots leadership
Demonstrated responsiveness to diversity and social justice at program & leadership levels
Qualified and well-trained volunteers or staff
Clear vision for the organization and its programs
Inclusion of constituents in organizational planning
Organization budget of less than $1 million

THE DOUTY FOUNDATION

P. O. Box 1437 § Philadelphia, PA 19105

Executive Summary (please limit the Executive Summary questions to one type-written page in total; ie. answers to all 4 questions fit on one page):

  1. Mission of Organization:
  1. Year Founded:
  1. Describe how your organization or project provides educational opportunities for communities/youth.

3. Brief Summary of Grant Request:

4. What positive change do you expect to result from your program or project?

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Description of organization’s:

  • Purpose and what makes its services unique
  • Overall goals and objectives
  • Current programs, activities and service statistics (who, what, where, when, how and why)
  • Organizational strengths
  • Recent accomplishments, including what makes the organization unique
  • Unmet needs your organization seeks to address

-Age

-Neighborhoods/schools

-% living at or below the poverty level

-Ethnic/racial background

-Level of English proficiency

-# of children/youth/adults your organization will serve in the coming 12 months and what percentage of your overall population are children/youth

1. Describe how your organization partners or collaborates with other organizations and in what capacity.

2. Does your organization charge fees for participation in any of its programs or services? Yes or No. If yes, please explain the fee schedule and any financial accommodations for those unable to pay.

3. What results is your organization seeking to achieve? How do you track progress towards these results and learn from them?

4. Please list major funding sources, with amounts of 5 largest grants in past 2 years.

-Organizational budget that includes income and expenses

-Project budget, if applicable, that includes income and expenses

-Most recent 990 or audited financial statements or year-end financial statement (if organization budget is >$250,000.00)

-Copy of 501-c-3 determination letter

-Resumes of key staff

-Organizational Composition– please use template

-Flyer, brochure or media article about organization/project

______

Questions:

Please contact Jennifer Leith, Executive Director

215.620.1869

P.O. Box 1437

Philadelphia, PA 19105

ORGANIZATIONAL COMPOSITION
Fill in ALL of the fields below. If none, enter 0.
If you do not know exact numbers, please estimate.
Fields left blank will be interpreted as your organization having no representation for that particular constituency.
Percentages will calculate automatically. The percentages do not need to add up to 100.
Board / Staff / Core Volunteers* / Total Base / Members***
# / # / # / #
Number of People
in Each Leadership Position
Board / Staff / Core Volunteers / Total Base / Members
# / % / # / % / # / % / # / %
Race/Ethnicity
Arab
Asian / Pacific Islander
Black
Caribbean
Latino/a
Mixed Race
Native American
South Asian
White
Other (please specify in next line):
Low-Income
Youth
Seniors
Immigrant
Disabled
LGBTQ
Women
* Core volunteers are often leaders of organizations that have no staff or board.
** Active Members are members who show up to meetings and events consistently.
*** Total Base/Members includes everyone on your mailing list, dues paying members etc.