UCSFUniversity Community Partnership Council

2009 Grants Program

APPLICATION COVER PAGE

Applicants: Attach this Cover Page and a copy of your 501(c)(3) letter to your application.

Project Information

Project Name
Community Partner
University Partner
Project Budget
Amount Requested
Project Focus (Check all that apply):
Service Learning
Educational Outreach
Community Engaged Evaluation and Research
Workforce and Economic Development
Project Description:

Who is the target population for your project? Please prioritize top three by indicating 1, 2 and 3.

African / Homeless / People with AIDS/HIV
African American / Immigrant/ Refugee / People with Disabilities
Asian/ Pacific Islander / Indigenous/ Native American / Seniors
Caribbean / Jewish / Students
Chicano/a / Latino/a / Women
Children (age 3-12) / Low-income / Workers
Faith Community / Multi-racial / Youth
Gay/ Lesbian/ Bisexual/Transgender / Philanthropists / Other:
General Population / People of Color
In which neighborhoods in San Francisco will you work?

Community Partner Information

(Note: Unless otherwise specified in your proposal, grant monies will be disbursed to the community partner.)

Community Organization Name:
Executive Director:
Project Contact Person: / Title:
Address:
City: / State: / Zip:
Phone Number: / Fax Number:
Email Address: / Website:
IRS employer identification number (EIN): / Year Founded:
Fiscal Year Ends on (insert date): / Current fiscal yr. organizational budget: / $
Tax Status: 501(c)3 Public Charity 501(c)3 Private Foundation
501(c)4 Social Welfare Organization Foreign Charity
** If your tax status is pending, or if you are not a 501(c)3 organization, please provide the following fiscal sponsorship information, along with a copy of your letter of agreement with the fiscal sponsor:
Fiscal Sponsor Organization:
Contact Person: / Title
Phone number: / Fax Number:
Address: / City: / Sate: / Zip:

What are the strategies employed in your program work?

Please prioritize top three by indicating 1, 2 and 3.

Arts/ organizing / Education / Policy/ Public Reform
Advocacy / Electoral reform / Religious
Coalition work / Grassroots organizing / Research
Community development / Legal / Spiritual/ Healing
Cultural work / Media / Training/ Technical Asst.
Direct services / Philanthropy / Other:

University Partner Information

University Partner:
Project Contact Person: / Title:
Address:
City: / State: / Zip:
Phone Number: / Fax Number:
E-mail Address: / Website:
**If the UCSF primary contact is a student, please include the name and contact information for the Faculty Advisor below**
Faculty Advisor Name: / Title:
Email Address: / Phone Number:

Application Cover Page

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