Program committees of Pi Tau Omega Chapter of Alpha Kappa Alpha Sorority, Incorporated applying for a grant are expected to address Pearls of Service Foundation program priorities. Identify no more than three major program priorities your program addresses.

Amt. Requested:$ 750.00 / Date Requested: 9/14/17 / Date of Project/Program: 10/16/17
Program Committee: Childhood Hunger CID / Committee Chairman: Twila Leigh
E-Mail Address:
Name of Project/Program: Childhood Hunger Community Impact Day
Description and Objective of Program: PTO partner with Cleaners Food Bank and Kids helping Kids org to purchase, assemble and dliver 50 bags of groceries and 50 backpacks to go to needy teens and young adults who have aged out of the foster care system.
What is your target audience for this project/program? homeless / low income teens
What other partnerships are involved in this project/program? Cleaners
Check Issued for Disbursement of Funds:
Yes Payable to: Twila Leigh
No Other: (Please reframe from requesting funds to individuals committee members)
Other request for reimbursement of receipts with vouchers
Budget for Project/Program
Income / Budgeted
Income requested: / $ 750
Income from other sources: / $
Total of Income / $ 750
Expenses
purchase of canned goods / $ 750
$
$
$
$
$
See attached / $
Total Expenses / $ 0
/ PROGRAM TARGETS
Target 1 – Educational Enrichment
Target 2 – Health Promotion
Target 3 – Family Strengthening
Target 4- Environmental Ownership
Target 5 Global Impact
Other – Please explain
Childhood Hunger Community Impact Day

I certify that the information I have provided on this form is complete and accurate. I authorize the Pearls of Service Foundation to use information supplied here solely to assess eligibility for this mini grant award. I certify that any photographs containing pictures of children have parental consents on file and may be use in any publication of the Pearls of Service Foundation.

Approval of Executive Committee: Yes No Budgeted Request Non-Budgeted Request

President of Pi Tau Omega Chapter: / Date:
Program Chairman of Pi Tau Omega Chapter: / Date:

Reviewed and Approved by Pearls of Service Foundation:

President Yes No Date: Initials: Vice President Yes No Date: Initials:

Summary of Project/Program

At the completion of the project or program, complete the summary of the project/program. Provide photographs if available of the event. Also, provide a copy of the parental consent form with your summary.

Amt. Requested: $ / Date Requested: / Date of Project/Program:
Program Committee: / Committee Chairman:
Name of Project/Program:
How many individuals in the community did the project/program impact?
Objectives were met: Yes No
Summarization of participations in Project/Program:

Budget for Project/Program

Income / Budgeted / Actual
Income requested: / $ / $
Income from other sources: / $ / $
Total Income / $
Expenses
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
Total Expenses / $ / $
Profit Realized No Yes indicate amount in actual column / $

Pearls of Service Foundation 32455 West 12 Mile Rd, P.O. Box 3342, Farmington Hills, Michigan 48333