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

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Name of Organization *

Charitable Registration Number (if applicable)

If not applicable, please write N/A

Address *

Street Address

Street Address Line 2

City Province

Postal Code

Phone Number *

Please enter a valid phone number.

Organization's Email Address *

Is your organization a Lake Country Co-op member? *

Yes No

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? *

Yes No

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.

Name *

First Name Last Name

Phone Number *

Please enter a valid phone number.

Email *

example@example.com

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 & Culture Youth Programs Sport & Recreation Education Environmental Programs Community Initiatives Other

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? *

Yes No

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 Minority Adults Children & Youth Families Seniors Other

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 channels Testimonials from partners and participants Other

Will you be purchasing other supplies from Lake Country Co-op? Check all that apply.

Food Liquor Home Centre (Lumber, Hardware, Paint, Seasonal Items, etc) Fuel Other

Signage. Check all that apply. *

Permanent Temporary None

Media Channel Recognition. Check all that apply. *

Media issued press release Invited media annoucement/event Social Media mentions & tags

Recognition through organizational or public media platforms. Check all that apply. *

TV Spots Radio Spots Newspaper Newsletter Posters Publication or print media Digital Ad Program Ad Organization's website

Recognition through social media platforms. Check all that apply. If other, please specify. *

Facebook Instagram Twitter Other

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.

Please upload additional information if you feel that it is needed

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Request for Donation Application

Organization Information

Contact Person for Project/Initiative

Tell us about your project/initiative

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