Please use the following form as your application for the Youth Leadership Grant process. The deadline for this year’s program is January 17, 2017.

Applicant Name: *
E-mail: *
Name of Program *
Phone: *
Agency Director: *
Program Contact Person if different from person listed above:
Contact E-mail:
Does your organization hold not-for-profit corporate status? (i.e. social service agency, school, municipality, church): *
Total Program Cost: *
Program time-frame (From/to): *
Amount of funding requested from Youth Leadership: *
Estimated number of persons to benefit from program: *
Briefly describe the program/service for which funding is requested: *
How was the need for the proposed program/service determined? *
Describe how the proposed program/service will impact the need identified above. *
What are the primary objectives of the proposed program/service? *
How will you evaluate the proposed program/service? *
How will this program/service be supervised by the organization? *
Provide an itemized income and expense budget for the proposed program/service. Use this space or e-mail to *
Indicate donated resources which the program/service will utilize (i.e. use of space, postage, telephone.) Identify what linkages this program will develop with other organizations and community resources.
Input the code for verification:

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