foundation logo GRANT REQUEST

This form was designed to provide potential donors and the Grant Committee with required information concerning your request. Review the entire form and then fill it out in detail. Incomplete forms will delay the process and could be returned to the requester. Please type or print only. Attachments are accepted. Questions may be directed to the Foundation at 847-548-7032. Thank you for applying to the SEDOL Foundation.

REQUESTER INFORMATION

Requester Name: _________________________________________________________________________________

Address: _______________________________________________________________________________________
Street City, State ZIP code

Telephone and fax numbers: ______________________________________________________________________

Relationship to grantee(s): __________________________________________________________________________

GRANT INFORMATION

Amount requested: $_____________________ Project Name: ______________________________________

State the specific purpose of funds requested and the specific objectives you hope to achieve for the student(s) with these funds: _______________________________________________________________________________________________

_______________________________________________________________________________________________

What type of activities will be required to meet the objectives of this request? _______________________________________________________________________________________________

_______________________________________________________________________________________________

Provide a budget of how funds will be spent. For programs or projects, provide a detailed budget and time frame of program or project. For equipment, provide a detailed description including suggested vendors.

_______________________________________________________________________________________________

Are you aware of any other Foundation grant requests similar to this proposal? _____Yes _____No

Have requests been made to other organizations? _____Yes _____No

If yes, list names and contacts of all organizations contacted. If no, explain why no other sources were contacted.

_______________________________________________________________________________________________

How does this grant request reflect your school’s mission or the SEDOL mission?

Does this grant request reflect sound instructional practices?

_________________________________________________________________________________________________

How will documentation be presented to show the success of this request?

__________________________________________________________________________________________

How do you plan to sustain this program/project beyond SEDOL Foundation funding? (i.e. Add budget line item, apply to other Foundations, sale of merchandise, etc.)
__________________________________________________________________________________________

GRANTEE INFORMATION

Group or individual benefiting from grant: _______________________________________________________________

Address: _____________________________________________________________________ Street City, State ZIP code

Contact: _________________________________________________

Telephone: ____________________________

For groups, state total number to be served, ethnic composition (i.e., 25% Caucasian, 15% Black, 60% Hispanic), age range and geographic location:

_________________________________________________________________________________

For individuals, provide the following information. All data provided to the Foundation is treated as strictly confidential. Income verification may be requested by the Foundation.

School and/or special education program attended by individual: ____________________________________________

Date of birth: __________________________ Disability: _________________________________________________

Does the individual currently receive Medicaid or SSI? _____Yes _____No

Does the individual qualify for free or reduced lunches at school? _____Yes _____No

Describe any unusual circumstances (i.e., medical costs, financial burdens, unemployment, family illnesses, etc.).

___________________________________________________________________________________

Annual Income (Include all sources of income such as wages, public aid, child support, and other government assistance.)

_____$0 to $15,000 _____$15,001 to $25,000 _____$25,001 to $40,000 _____Over $40,001

Number of persons in household: _____ Number of adults: _____ Number of children (age 18 or under): _____

Ages of children in household: ______________________________________________________________________

VERIFICATION

I understand that this application will be kept confidential and will be evaluated to determine whether the request qualifies for funding. I understand that funding is dependent on the availability of SEDOL Foundation funds. All of the above information is true and the information provided is complete.

Signature of Requester: ___________________________________________________________________________

Relationship to Grantee: ___________________________________________________________________________

Date: ____________________________

Note: If the grantee is a minor, the signature of the parent or guardian is required.

Signature of Parent/Guardian: ______________________________________________________________________

Date: ____________________________

My Sector Supervisor/Principal reviewed this request. _____Yes _____No

Name of Sector Supervisor/Principal: _________________________________________________________________

When completed, return the form with attachments to the following address. The Grant Committee meets quarterly throughout the year. If you have any questions, contact the Executive Director at the SEDOL Foundation (847-548-7032).

SEDOL Foundation
P.O. Box 527
18160 Gages Lake Road
Grayslake, IL 60030

... providing resources for Lake County’s special children
FORM #638
Rev. 10/04