Greek Orthodox Ladies Philoptochos Society, Inc.
Metropolis of Boston Philoptochos
National Philoptochos Children’s Medical Fund
Grant Request Form
This document seeks to explore your program, its history, track record andneeds
The deadline for email submittal of your grant request is Friday, May 22, 2015.
Eligibility Requirements:
In order to be eligible for consideration, all applicant organizations MUST:
· Have current 501(c)(3) status from the Internal Revenue Service.
· Be located in or serve populations of the Metropolis of Boston, which includes the states of Massachusetts, Maine, New Hampshire, Rhode Island and Vermont, and the areas in the state of Connecticut surrounding the cities of Danielson, Enfield, New London and Norwich.
· Address as their mission or project intent one of the Priority Issues for funding.
Exclusions:The CMF of the National Ladies Philoptochos Board will not consider requests for:
· Direct grants, scholarships or loans for the benefit of specific individuals.
· Projects of organizations whose policies or practices discriminate on the basis of race, ethnic origin, sex, creed or sexual orientation.
Part I: Organization Information
Name of Organization: ______
Mailing Address: ______
City: ______
State: ______Zip/Postal Code: ______
Phone Number: (_____) - ______
Fax Number: (_____) - ______
Website: ______
Primary Contact: ______
Title: ______
Primary Contact Phone Number: (____) - ______
Primary Contact Fax Number: (____) - ______
Primary Contact Email: ______
Part II: Mission Statement (Statement of Purpose)
What is the mission of your organization? ______
______
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How would you describe your current constituencies? ______
______
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Which geographical locations do you serve? ______
______
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Who currently serves on your organization’s board?
______
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Provide a brief history of your organization. ______
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Part III: Pertinent Statistics:
Total annual budget in the last completed fiscal year: ______
______
How many people did your organization serve last year? ______
Number of full-time employees does your organization employ: ______
Is your organization a 501(c)(3) public charity?
Yes ____ No ____
If so, please provide your organization’s Employer Identification Number (EIN)?
______
Did your organization have an external financial audit conducted in the last fiscal year?
Yes ____ No ___
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Grant Request Information
Project/Program Title:
______
Project Description: (Comprehensively describe the purpose of the project or program.)
What issues or needs will the CMF grant help your organization address? ______
______
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What specific outcomes or deliverables do you plan to achieve with this project?
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How will the funds be used?
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How many children and families/people do you estimate this project/program will serve? ______
How would you describe the specific constituency this grant is designed to affect?
______
What is the total estimated budget/annual cost of this specific project or program?
______
What other grants have you received for this project or initiative? ______
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Please provide us with an example of how your program has enhanced the life of a child, or will enhance the life of a child if put into place. ______
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Please complete this form and send it, preferably via email, with any other pertinent documents to:
Helen Lavorata
Director, National Office
Greek Orthodox Ladies Philoptochos Society, Inc.
126 East 37th Street
New York, NY 10016
(email)
212-977-7770 (office phone)
212-977-7784 (office fax)
If you have any questions, please contact:
Frances Levas, President
Metropolis of Boston Philoptochos
33 Gertrude Street
Watertown, MA 02472
617-519-3422 (cell phone)
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