Youth Grant Application

I. Contact Information

Organization/School/Club Name: *

Address: *

Contact Person: *

E-Mail: *

Telephone: *

Total Project Budget: * $

Amount Requested (up to $1,000): * $

II. Assurance Statement

To be considered for funding by the Madison Civics Club, an organization must complete our application form and return it along with this signed assurance statement and a copy of the organization’s 501(c)(3) or equivalent determination letter from the IRS. For online application submission, type the name. If your organization or group is selected to receive a grant, we will need a signed copy (download PDF of Assurance Statement).

On behalf of the requesting organization, I hereby certify that the requested grants will be used for the purposed stated on the application form and will not be used in any program that otherwise discriminates on the basis of race, sex, religion, color creed, disability, sexual orientation, national origin, ancestry or age, or any other basis prohibited by applicable law.

Signature of Authorized Official:

Print Name: *

Date: *

Name of Requesting Organization: *

III. Proposal Description

Briefly outline your project and explain specifically how the requested funding will be used and what community needs will be addressed.: *

Who and approximately how many people will benefit from this funding? How will they benefit?: *

Please describe your program, including how your students are involved in civic and/or volunteer projects.: *

Please indicate the Madison Civics Club program that you are interested in having students attend. Describe how your group has been involved in this interest area as well as how students would benefit from hearing this speaker.: *

Will the project acknowledge Madison Civics Club support? If so, how?: *

Madison Civics Club will pay for the lunches of the students and chaperones. Additional adult guests may purchase a ticket at the reduced price of $15. The club will also pay for parking for students and chaperones.

Number of Chaperones: *

Number of Students: *

Number of additional adult guests @$15.00: *