Grants Prep Form

Theda Fields White, CEO

1352 Baldwin St

Jenison, MI 49548) Phone: (616) 706-8568

General Information Form for Foundation and Grant Submissions

All questions contained in this questionnaire are strictly confidential and will become part of your file.

Organization Name

Street Address

City, State, Zip

Phone Number

Please enter a valid phone number.

Email Address

example@example.com

Website

ORGANIZATION MISSION / VISION STATEMENT

PLEASE PROVIDE A BRIEF HISTORY OF YOUR ORGANIZATION

Please provide a brief history of your organization!

What is the purpose of the organization?

What are the goals of your organization?

What are your organizations key accomplishments?

What is the number of professional and support staff/volunteers employed by your organization?

What is your staff or volunteers professional experience?

Who have been your key funders or funding support?

Who do you network or receive referrals from in the community?

Are there other programs in the community that provide your same service? If so do you collaborate?

Please provide a synopsis or brief description of your program.

Please provide a detailed description of your program, i.e.; days, times and frequency of activities.

What critical need does your program address in the geographic area served?

Does your program/project designed to attract minorities as participants? If so how?

Who is your target population?

Describe the achievements of your program/project.

Any certifications, awards, recognitions? (please identify).

What area do you address (education, mentoring, teen pregnancy etc Geographical area served Ethnicity

Tell us more about who you serve.

What are your program objectives (how do you arrive at your results)?

What is your anticipated timetable?

Describe the methodology you use to capture and track the actual results of your program/project?

What are your program service numbers? How many did you serve?

How many completed the program?

What are your program challenges?

Anticipated community impact?

Please attach your annual budget.

Please attach your program budget.

Please attach your Board of Directors matrix.

Please attach your 501 C 3 Letter of Determination (or state "on file with Help 4 Us, Inc.)

By signing below, I hereby acknowledge that I have completed this form to the best of my ability. *

MEASUREMENTS OF PROGRAM/PROJECT SUCCESS