BRCF GRANT INTEREST FORM

Please complete this form to be eligible for a grant from the Wortman Family Foundation Fund.

Jordan England, Grants & Nonprofit Relations Director, will follow up with the grant contact listed after November 1st. For questions regarding the completion of this form, or the Foundation's grant process, please contact Jordan at 317.392.7955 ext. 101 or jengland@blueriverfoundation.com.

Organization Name

Address

Street Address

Street Address Line 2

City

Zip Code

Phone Number

Area CodePhone Number

Website

Orgranization President or Director

First NameLast Name

Grant Contact

First NameLast Name

Grant Contact Title

Grant Contact Phone

Area CodePhone Number

Grant Contact Email

example@example.com

Is your Organization a registered 501c3?

YesNo

Which county do you serve?

HancockShelbyBoth

Areas of Interest

EducationHealthCommunity EnhancementOther

Grant Amount Requested ($2,500 - $25,000):

Provide a Brief Summary of Your Grant Request.

0/250