2021 SAM Grant Application

Name of Organization *

Name of Organization's Director *

First

Last

Address of Organization *

Address Line 1

Address Line 2

City

State

Zip Code

Organization's Phone Number *

Organization's Website *

Name of Organization's Contact Person *

First

Last

Email of Organization's Contact Person *

Email

Confirm Email

Organization's core focus, mission, a/o activities: *

Number of people that your organization serves:

Grant Amount Requested: *

(In US Dollars)

Please describe how the requested funds would be used. *

Please provide the justification for the requested grant funds. *

Expected timeline and the approximate number of people who would benefit from the requested grant: *

How will you measure success for the grant funded program? *

Total Size of the Organization's Annual Budget: *

(In US Dollars)

Please identify percentages of your annual budget income received from: 1) local and county government; 2) Federal government; 3) charitable foundations; 4) churches; 5) individuals; 6) program service; 7) other. *

Exact name of organization as it should appear on the check: *

Exact address for mailing the check: *

Address Line 1

Address Line 2

City

State

Zip Code

Have members of Rock Spring UCC been involved in the activities of your organization? *

If so, please list the names of volunteers from Rock Spring UCC:

Do you have volunteer opportunities that might be filled by members of Rock Spring UCC? If so, what areas?

Our congregation is working to become a more just, anti-racist congregation. Has your organization taken steps in this type of work? Have you had any successes you wish to share?

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