ROTARY CLUB OF FLAGLER COUNTY GRANT APPLICATION Date Organizational Information Name of organization Address Mailing address (if different) Type of organization: Tax ID # If you need additional space for any answer, please continue on a separate sheet of paper Affiliations with other organization? Contact Information Name E-mail Title Phone 1. How long has organization been in existence? 2. Have you previously been awarded or have pending grants by another Rotary club or other entity? Or have you received donations from the Rotary Club of Flagler County in the past? Yes No If yes, please provide information as to granting organization. Please include year, purpose and amount of grant: Rotary Club of Flagler County Grant Application Page 1
3. Describe the mission and purpose of the organization: 4. Does your organization have an annual budget? Yes No If yes, please attach a copy. 5. Does your organization have a financial statement? Yes No If yes, please attach a copy. 6. Please list the organization s current board members and officers: 7. Geographic area served by the organization? 8. Does your organization hold IRS Section 501 (c) (3) exemption status? Yes No If yes, please attach a copy. 9. Are there other ways, other than financial, that Rotary can help your organization? 10. Would volunteers from your organization be willing to help with a Rotary project? Yes No Project or Program Information 11. Project or program title: 12. Amount of grant requested? 13. Provide preliminary budget of proposed expenditures: Rotary Club of Flagler County Grant Application Page 2
14. Describe the Project / Program for which you are seeking funding: 15. Is this a new project or an on-going project? New On-going. If on-going, please provide a brief history of your project: 16. What community(s) will the Project / Program serve? Please include target population and number: Rotary Club of Flagler County Grant Application Page 3
17. Describe the need for this Project / Program within our community: 18. Describe the goal, objectives and desired impact on the community on your Project / Program: 19. If the Project / Program is to last beyond this grant, how will you sustain the Project / Program after Rotary funds end? Rotary Club of Flagler County Grant Application Page 4
Grant Summary Please see our website www.flaglerrotary.org for further information regarding our current community service projects that we support such as: Polio Plus, Fantasy Lights, Scholar Athlete of the month, golf tournament, roadside cleanup s and the third grade dictionary project. Unless extenuating circumstances exist, our board of directors will consider requests received on a quarterly basis (March 15, June 15, September 15 and December 15). If a grant is approved, you will be required to furnish our club with a report on the outcome of the project. Applications and questions should be mailed to the Rotary Club of Flagler County, Post Office Box 353004, Palm Coast, Florida 32137. Grant Conditions By executing and submitting this grant application, the applicant agrees that grants shall not be utilized by or for: Organizations which practice any form of discrimination. Organizations whose primary focus is political, lobbying, or campaigns of candidates for public office. Organizations that are grant-making bodies themselves. Religious organizations for the purpose of promoting a specific religion. No part of the grant shall be used for the purposes that do not exclusively promote charitable purposes within the meaning of section 501 (c) of the IRS code of 1986, as amended. No part of the grant shall be used for the principal purpose of carrying on a trade or business for profit. No part of the grant shall be used for carrying propaganda, or attempting to influence legislation, or participating in, or intervening in (including the publication or distribution of statements), any political campaign on behalf of any candidate for public office. The applicant agrees that grant funds shall be utilized solely for the purposes set forth herein, adequate safeguards will be implemented to ensure same, and recipient will cooperate in any inspections or audits to ensure same. Accountings of the uses of such funds and adequate records thereof will be provided as requested. The Rotary Club of Flagler County is responsible for the manner of application of such funds, nor for the provision of additional funds, and any grant awarded shall not create a contractual, partnership, joint venture or other legal relationship. Rotary Club of Flagler County Grant Application Page 5
Grant Acknowledgement I certify that the information contained in this grant application is true and correct to the best of my knowledge, information and belief after reasonable inquiry. Organization: By: Name: Title: Date: For Club Use Date Received: Approved: Yes No Funding amount: Comments: Rotary Club of Flagler County Grant Application Page 6