Student Funding Committee: Mini-Grant Application

Luther Porter Jackson

Student Funding Committee: Mini-Grant Application

Mini-Grant Application Eligibility

Minimum requirements: University of Virginia students and registered student organizations may apply. Applicants must be students enrolled in an undergraduate or graduate program of the University, at the time of the application and for the period of the funded activity.

Additional requirements:

1. Individual students MUST be sponsored by an organization that is registered and active through the student activities center AND that is in good standing with LPJ.

Organizational Good Standing:

2. Each applying/sponsoring organization must have an active representative learning in the current Black Leadership Institute Module.

3. Each applying/sponsoring organization must have active executive representation on the Black Presidents Council.

Funding

Requests may be made for up to $500.00. The LPJBCC SFC Fund may be used for initiatives such as the following:Guest speakers on topics relevant to the Black Experience, Special program(s) intended to increase respect for diversity and individual differences, or Events that expand the inclusion of issues related to race, ethnicity, gender, sexual orientation, age, social class, physical ability or attributes, religious or ethnical values system, national origin, and political beliefs in the way the University thinks about Black as a social construct.

See for a full description of application. Applications are only accepted in person. Please return to OAAA Main Office,#4 Dawson’s Row between 8 am and 5 pm.

Organization Name: ______

Registered with Student Activities Center?: YES or NO

Is Organizations Currently Active? YES or NO

Is Organization in Good Standing with LPJ? YES or NO

Primary Contact Name: ______Title: ______

E-mail: ______Phone: ______

Secondary Contact Name: ______Title: ______

E-mail: ______Phone: ______

Organization Information

Please select any of the following that describe your organization:

Academic/Professional / Greek (Fraternity/Sorority)
Athletic/Recreational / Honorary
Creative Arts/Expression (Visual, Performance and/or Exhibition) / House Council
Community Service / Cultural/Ethnic
Environmental / Political
Graduate / Publications/Journalism
International / Religious
Science/Technical / Social Justice

Describe the overall purpose/mission of your organization and the planned initiatives and activities intended to uphold said objective(s).

______

______

______

______

No. of active student members: _____ No. on group e-mail list: _____

Avg. attendance at group meetings:(Executive Board meetings, committee meetings, event planning meetings, etc.)______

Average attendance at events:(Note: If new organization, please project event attendance at future programs. If organization is not involved in event planning, please write "N/A") ______

How often does your group meet? ______

Financial Information

PLEASE FILL OUT ALL OF THE FOLLOWING INFORMATION CLEARLY

If there is any further information that may provide us a more complete financial picture of your organization, please attach it to the end of this application. This especially applies to club / recreational sports or groups with exceptionally large budgets. Adding your own budget cannot replace this form. It can only be used as supplementary documentation to clarify the above information.

Section 1 - Account Balances
Please list the balance of any and all accounts your group accesses. Also include the balances of any external, commercial bank accounts your group holds (e.g. Wachovia, Bank of America, etc.)
Account Location (CITY/Bank Name) / Balance
$
$
$
Total Account Balance (sum of above columns) / $
Section 2 – Funding Received and/or Raised
Please identify ANY other funding (excluding membership dues) that your group has already received/raised or is GUARANTEEDto receive at some point over the semester. These sources could include other UVA funding bodies (StudCo, Student activities funding Committee, departmental grants, UPC, etc.), external donations, national organization allocations, etc.
Funding Source / Expected Amount
$
$
$
Total Expected Funding (sum of above columns) / $
Section 3 – Funding Pending
Please estimate ANY other pending funding (excluding membership dues) that your group could POSSIBLY receive at some point over the semester. These sources could include other UVA funding bodies (StudCo, Student activities funding Committee, departmental grants, UPC, etc.), external donations, national organization allocations, etc.
Funding Source / Expected Amount
$
$
$
Total Pending Funding (sum of above columns) / $
Section 4 – Dues
Please estimate all dues that are not reflected in any of your bank accounts at the time of filling out this application. Leave blank if dues have already been added to your accounts.
Expected Number of Dues-Paying Members / (1)
Dues Charged Per Member / (2)$
Total Dues Revenue (Field (1) x Field (2)) / $
Section 5 – Admissions Revenue
Please estimate the revenue your group will accrue from the event(s) you are applying for. Please use the prescribed formula below.
Event #[ ] / Expected Number of Participants / (1)
Admissions Charged Per Person / (2)$
Percentage of Revenue Donated to Charity (round to nearest decimal) / (3) 0._
Admissions Revenue for Event #[ ]
(Field (1) x Field (2)) x (1 – Field (3)) / (4) $
Event #[ ] / Expected Number of Participants / (5)
Admissions Charged Per Person / (6)$
Percentage of Revenue Donated to Charity (round to nearest decimal) / (7) 0._
Admissions Revenue for Event #[ ]
(Field (1) x Field (2)) x (1 – Field (3)) / (8) $
Total Admissions Revenue for all Events
(Field (4) + Field (8)) / $
Cash Flow Summary
Please copy the values from the above worksheet to create your cash flow summary.
Total Account Balances (section 1) / $
Total Expected Funding (section 2) / $
Total Dues Revenue (section 4) / $
Total Admissions Revenue (section 5) / $
--MINUS--
Total Debt & Liabilities (section 6) / $
Total Projected Expenses (section 7) / $
Cash Flow / $
Section 6 – Debt & Liabilities
Please identify all pre-existing debts or liabilities your group currently holds. This includes all expenses incurred thus far which cannot be put to use this academic term.
Debt / Liability Description / Amount
$
$
$
Total Debt $ Liabilities / $
Section 7 – Projected Expenses
Please identify all reasonable projected expenses for your group this academic term. This includes any future costs, events, etc., you have OTHER THAN those expenses for which you are applying.
**For each projected expense please attach supplementary documentation detailing the legitimacy of this forecasted amount (i.e. expense calculation, past budgets/expenditures, etc.)
Projected Expenses Description / Amount
$
$
$
Total Projected Expenses / $

Event Description No. [____]

Complete this page for each event. If you are holding a series of similar events, e.g., weekly speakers or meetings, list it as one event.

Event name: ______

Event date(s): ______Event location: ______

1. Briefly describe this event. What is its overall purpose?

______

2. Describe how this event will impact our campus and the student body.

______

3. If applicable, please describe how the program fulfills one of LPJBCC core areas ie., community service, education, leadership development, and social action.

______

4. Describe how your events will include other groups or departments.Which other groups or departments are you sponsoring this event with?

______

______

5. How many participants do you expect? ______

6. Will you charge admission? YES NO

• If so, how much (per person)? ______
• Will this be donated to charity?______
• What percentage will be donated? ______

7. Who is eligible to participate? ______

8. Are your date(s) and location (s) confirmed? YES NO

Budget for Event No. [____]

Please fill out this form for each corresponding event description page. List ALL expenses. Please use the notes sections below to explain any costs in greater detail.

Category:Total Cost:Amount Requested Rank:

From LPJBCC SFC:

Advertising & Publicity

We strongly recommend that you attach a copy of all posters/flyers to the end of this application.

• Posters/Flyers$______$______
• Other: ______$______$______

Notes:______

Operations

• Office Supplies (please specify)

______$______$______

• ______$______$______

Notes:______

Printing & Publications $______$______

We require that you attach a copy of all publications to the end of this application.

Facilities Rental

• Equipment (please specify)

______$______$______

• ______$______$______

• Room Rental$______$______

Notes:______

Services

• Speaker Honorarium$______$______
• Speaker Travel$______$______
• Speaker Lodging$______$______
• Other: ______$______$______

Capital Goods

• T-Shirts$______$______
• Computer/Equipment$______$______

Food ______$______$______

Other: ______$______$______

TOTAL EXPENSES$______$______

Summary of Requests

Total Expenses Amount Requested

From LPJBCC SFC

ITEM #1$______$______

ITEM #2$______$______

ITEM #3$______$______

ITEM #4$______$______

ITEM #5$______$______

ITEM #6$______$______

TOTAL$______$______

Optional

Suggestions for improving our LPJBCC StudentFunding Committee process: ______

______

DELIVER A HARD COPY TO OAAA MAIN OFFICE BETWEEN 8-5PM.

MAKE SURE IT IS SIGNED AND TIME STAMPED

BY MS. COMFORT (OFFICE MANAGER)

______

Ms. Comfort, OAAA Office Manager Date Time

NO APPLICATIONS WILL BE ACCEPTED

ELECTRONICALLY (IE., EMAIL OR FAX).

The below-signed representatives have read and understand this agreement; at least oneorganization’s signer must be in good standing with Luther Porter Jackson Black Cultural Center:

______

Name (Authorized Signer for Group) Position Date

______

Name (Group Member, different than above) Position Date

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