2017GrantApplication

There are two grant categories available from the Rita J. Bicknell Women’s Health Funds.

Grant requests greater than $2,000 are funded from the Women’s Health Fund Giving Circle.

Grant requests $2,000 or less are funded from the Circle of Friends Giving Circle.

SECTION A – APPLICANT INFORMATION

Legal Name of Organization: ______

(Should be the same as on the IRS Determination Letter)

Mailing Address: ______City: ______State: ______Zip: ______

Contact Person: ______Title: ______

Phone Number: ______Email: ______

  • Is your organization an IRS 501(c)(3) not-for-profit? Yes_____ No_____

(If Yes, FEIN #______)

or

If yes to the questions below, proof of nonprofit status is not needed.

  • Is your organization a unit of the government?Yes_____No_____
  • Is your organization a religious institution?Yes_____No_____
  • Is your organization an educational institution?Yes_____No_____

Have you received a RJB Women’s Health Fundgrant before? YES_____No_____

SECTION B – AMOUNT AND TYPE OF SUPPORT REQUESTED:

Project Title: ______

Dollar amount being requested: $______

Briefly describe the use of the grant monies: ______

______

______

Estimated number of females to be served: ______

SECTION D – GRANT APPLICATION NARRATIVE:

The mission statement of the Rita J. Bicknell Women’s Health Fund is “To improve the health and well being of women by supporting education, increasing awareness and sharing quality of life opportunities to benefit all women.” Please consider this mission statement as you complete your grant application.

1. Organizational Background: Briefly describe your organization’s history, mission and goals. Include a brief overview of any current programs or activities.
2. Description of Need: Briefly describe the need in women’s health you have identified as underserved or not served at all. Describe how you determined this need.
3. Program Description: Specifically describe the program, detailing the activities and how the funds will be used. Include a description of the population to be served, and explain how this program will meet the need you have identified.
4. What will the success of your program look like? Include the details you will use to determine the success.
5. What are your plans for this project if the Women’s Health Fund is not able to fully fund your request?
6. Is this program currently facilitated by another agency or organization in the area?

SECTION E – BUDGET NARRATIVE:

Provide adetailed, line-itembudget for this program/project.

Explain with detail how the amounts were determined. Please note if the funds you are requesting will be used as a match or to leverage other sources of revenue.Include a list of any other funding sources for this program/project.

SECTION C – NAMES OF AUTHORIZATION:

Organization Organization President/

Administrator: ______Chairperson: ______

SUBMISSION INSTRUCTIONS:

All applications must be:

  • Received by 3:30 pm, Friday, April 28, 2017
  • Typed
  • One-sided
  • Not stapled

Please include:

  • Mission statement
  • Board of Directors list
  • Proof of nonprofit status if not already on file at the CFSEK office
  • Above information ONLY. No cover letters or letters of support.

Email your application packet to:

OR

Mail your application packet to:

Community Foundation of Southeast Kansas

P.O. Box 1448

Pittsburg, KS 66762

OR

Deliver your application packet to the Foundation office at:

100 South Broadway, Suite 100

Pittsburg, KS 66762

Office Hours are Monday-Friday 8:00 a.m. to 4:30 p.m.

Please call 620.231.8897 with any questions.

Contact the CFSEK office within one week of submitting your application if you have NOT received a

confirmation message.

The 2016 final grant report will be part of the grant review process.

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