WH Rotary Fund Request for Organizations

Tell us about your organization\cause

Let's get some more info...
Date

MonthDayYear
Date
Your Name

First NameLast Name
Organization
Summary of Your Needs
Organization Contact Name

First NameLast Name
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone
Please enter a valid phone number.
Organization Website
Contact Email
example@example.com
How are you involved with them?

As a volunteerAs an employee or agentNo, I am not
Is the organization "Not for Profit? (501.c.3)"

YesNoNot SureOther
If other, please describe:
What will the funds be used for?

Operating ExpensesPurchase of equipmentProgrammingOther
If other, please describe:
How much are you asking for?
Are there branding or publicity opportunities for our Rotary Club?

YesNo
Are you interested in a corporate or personal membership with our club?

YesNo
How many years has the organization been in existence (estimates are ok)?
What is your geographic area of focus (check all that apply)?

West HartfordHartford CountyState of ConnecticutNational and InternationalOther
Rotary International emphasizes the following areas of focus. Please check the boxes that are appropriate to your organization:

Peace and Conflict ResolutionDisease Prevention and TreatmentWater and SanitationMaternal and Child HealthBasic Education and LiteracyEconomic and Community DevelopmentProtecting the Environment
Urgency (1-5 with 5 being immediately)

1

2

3

4

5

1 is Within one year, 5 is Need Immediately
Are you already involved in Rotary?

YesNoin the past
If yes, let us know how and where!
Can we get your members involved with Rotary?

YesNoMaybe
Are you able to make a presentation at one of our meetings? (Mondays 12:15 pm at The Pond House Cafe in Elizabeth Park)

YesNo
Can our members participate in your program(s)?

YesNo
You can upload a supplemental file here (ie. a PDF for your event, etc.) :

Cancelof
Thank you for taking the time to fill out this form! If you have any questions, please contact Dr. Rick Liftig - rickliftig@gmail.com
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Tell us about your organization\cause