Request for Donation Application

Request for Donation Application
I have read and understand the donation guidelines and eligibility criteria. Our organization has not received a donation from Lake Country Co-op in the past 12 months. I am authorized to make an application on behalf of this organization.*

I agree and understand
Signature

Clear
Organization Information
Name of Organization*
Charitable Registration Number (if applicable)
If not applicable, please write N/A
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
Please enter a valid phone number.
Organization's Email Address*
Is your organization a Lake Country Co-op member?*

YesNo
What is your organization's Lake Country Co-op number?
Select the nearest Lake Country Co-op community near you*
Have you spoken with someone at Lake Country Co-op about this initiative?*

YesNo
If yes, please specify full name and location
Organization's Website
If not applicable, skip to next question.
Organization's Facebook Page
If not applicable, skip to next question.
Organization's Instagram
If not applicable, skip to next question.
Organization's Other Social Media Platforms
If not applicable, skip to next question.
Contact Person for Project/Initiative
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Tell us about your project/initiative
What is the name of the initiative/project you are currently applying for?*
Which category best describes this project/initiative? Check all that apply. If other, please specify.*

Arts & CultureYouth ProgramsSport & RecreationEducationEnvironmental ProgramsCommunity InitiativesOther
Please describe this project/initiative*
Project/Initiative start date:*
Project/Initiative completion date*
Total amount requested:*
Total budget for this project/initiative*
Have you applied for funding from other sources including government, foundations, grants, other retail competitors for this project?*

YesNo
Please provide further details about this funding
Where does this project/initiative take place? *
Please be as specific as possible
Who is your target audience for this project/initiative? Check all that apply. If other, please specify.*

Visible MinorityAdultsChildren & YouthFamiliesSeniorsOther
What benefits will Lake Country Co-op receive? Check all that apply. If other, please specify.*

Speaking opportunity - opening/closing ceremonies, ribbon cutting, keynote speaker, etc.Photos and/or video of initiative/project for use on Lake Country Co-op media channelsTestimonials from partners and participantsOther
Will you be purchasing other supplies from Lake Country Co-op? Check all that apply.

FoodLiquorHome Centre (Lumber, Hardware, Paint, Seasonal Items, etc)FuelOther
Signage. Check all that apply.*

PermanentTemporaryNone
Media Channel Recognition. Check all that apply.*

Media issued press releaseInvited media annoucement/eventSocial Media mentions & tags
Recognition through organizational or public media platforms. Check all that apply.*

TV SpotsRadio SpotsNewspaperNewsletterPostersPublication or print mediaDigital AdProgram AdOrganization's website
Recognition through social media platforms. Check all that apply. If other, please specify.*

FacebookInstagramTwitterOther
Your Comments
Is there anything else you would like to tell us about this project/initiative? *
What are you aiming to achieve through this project/initiative? How will you know if you are successful? *
For requests of $500 or more, we require completion of a post evaluation form within two weeks of the project/initiative completion date. Failure to provide a post evaluation form may impact future funding. Send completed post evaluation to info@lakecountrycoop.ca*

I understand and agree
Click this link to download the post evaluation form. The post evaluation form requires information to validate the success of the project/initiative. Photo's and samples of advertising material may be required.
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Request for Donation Application

Organization Information

Contact Person for Project/Initiative

Tell us about your project/initiative

Your Comments

Attachments