GRANT REQUEST

Request to: Dickey Foundation

Contact Name :

Contact Phone :

Contact E-mail :

Organization/individual Name :

Project Name (if any) :

Organizational Information

1. Organization's History :

2. Organizational Goals and Objectives (short-term and/or long-term) :

3. Programs and Services (briefly describe your organization's program and services) :

4. Organizational Structure (board, staff, volunteers) :

* A Diversity Data Form may be used to provide this data.

Proposal Information - Emergency Monetary Assistance

If you are requesting emergency Monetary Assistance

5. Description of Incidents or Illness :

6. Description of Need (Describe expenses to be covered, amount and duration) :

7. Provide details of other organization providing monetary assistance (Describe expenses to be covered,amount and duration) :

Proposal Information - General Support

If you are requesting general operating support, provide information about your organizations overall purpose, operating needs, and strategic plans

8. Description of Program/Project :

9. Description of Need (What is the issue you plan to address? What is your approach? What research supports your idea? How does your strategy differ from others in field?) :

10. Specific Activities (Include information about service delivery and/or timeline.) :

11. Objective and Goals for this Request (How wil this grant strengthen the organization, address the issues, make improvements, or achieve success? ) :

12. Evaluation (What are the anticipated outcomes and how will you know if you are successful? ) :

13. Other (Use this space to provide any additional information that you feel would be relevant to this grant request that is not covered in the section above or respond to any other questions an individual grant maker may have.) :

Budget Information

Use the Budget Forms to provide the organizational financial information and the program or project budget, both income and expenses. Use this section below to indicate what funding you have received from other foundations, and from which other foundations you plan to seek funding. Describe any unusual or special circumstances and provide an explanation/justification of funding request and the amount.

Narrative :