After submitting your online application, please print the completed form along with all other related attachments and mail to: 1000+ Club to Benefit Cancer, Inc., 6278 North Federal Highway, Suite 150, Fort Lauderdale, FL. 33308. All applications must be postmarked no later than September 12, 2019. Contact Merrill Thomas, VP 1000+ Club to Benefit Cancer, Inc. at 954-563-9225 or mthomas410@comcast.net with any questions.

CHARITABLE GIVING GRANT APPLICATION

  • Before preparing your application, please read the following
    Instructions carefully and provide all information requested.

    • Use 1 inch margins and nothing smaller than 12 point font size, single spaced.
    • Handwritten applications are not accepted.

    For questions while completing and submitting the application please contact
    Merrill Thomas, VP 1000+ Club to Benefit Cancer, Inc. at
    954-563-9225 or

    mthomas410@comcast.net

    PART I. Please fill out in its entirety the General Information and Certification of Accuracy and Compliance Sections of the Application.

    PART II. In a maximum of five (5) one sided pages, please provide short concise information in each of the areas discussed below. Label each section of your proposal using the six (6) categories presented in bold in the following instructions. Organize the sections of your proposal in the following order: Background, Proposal, Evaluation, Board, Staff, Finances and Project Funding. Please number the pages of your application.

    PART III. Attachments
    The following documents are required to be submitted with the Grant Applications for consideration by the 1000+Club to Benefit Cancer, Inc.

    Attachment A – Drug-Free Workplace Certification: Complete and attach the two (2) page form provided certifying that the Applicant Organizations will ensure a drug-free workplace.
    Requires original signature and notarization.

    Attachment BClient Non-Discrimination Policy: Include Applicant Organization’s current policy. Requires original signature.

    Attachment CEqual Employment Opportunity Policy: Provide Applicant Organization’s current policy. Requires original signature.

    Attachment DAmerican with Disabilities Act Policy: Include Applicant Organization’s current policy. Requires original signature.

  • PART I - A. GENERAL INFORMATION

  • Main Administrative Address:

  • Application Contact Person’s Name and Title:

  • Applicant Organization’s Fiscal Year:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Certification of Accuracy and Compliance

    I do hereby certify that all facts, figures and representations made in the application are true and correct. Further, all applicable statutes, terms, conditions, regulations and procedures for project compliance and fiscal control will be implemented to ensure proper accountability. I certify all funds requested in this application will not supplant any that would otherwise be used for the purposes set forth in their project and are a true estimate of the amount needed to operate the proposed project. The filing of this application has been authorized by the contracting entity, and I have been duly authorized to act as the representative of the organization in connection with this application. I also agree to follow all terms, conditions, and applicable federal and state statutes.
  • Date Format: MM slash DD slash YYYY
  • PART II - A. BACKGROUND

    In no more than ten lines, please describe the background and mission of your organization, incorporating the following points:
    • The year the organization began providing services to its clients;
    • A brief summary of its history;
    • Statement of its purpose, goals and objectives;
    • The geographic area(s) within Broward County served by the organization and its programs.
  • B. PROPOSAL

    The 1000+ Club to Benefit Cancer, Inc. awards project-specific grants to provide funding to selected 501(c) 3 Broward County cancer organizations through fundraising events and membership contributions to support cancer education and cancer patient services.
  • Describe the target population to be served. Please include the following breakdown: *Numbers served in last fiscal year
  • Economic status: What percentage of the total number of clients served in the organization is low income/working poor?
  • Racial/ethnic composition: (all totals should equal to 100%)
  • *Gender: (all totals should equal to 100%)
  • C. EVALUATION

    1. Provide the following information with data from the most recently completed program year, if applicable. Please complete for the program proposal being requested.
  • Most recently completed program year
  • Most recently completed program year
  • Most recently completed program year
  • Most recently completed program year
  • 2. Please provide the following information describing projected goals and outcomes for the current program year.
  • D. STAFF

    1. List the qualifications of the individuals who will direct and staff the program. Please include the following: Position/Job Title, Minimum Degree Required, Training and Experience, Main Duties and Percentage of time devoted to and funded by the project.
  • E. FINANCES

    Based on the information presented in your most recently-completed audit, please answer the follow questions, if applicable: 1.If your organization’s current liabilities exceeded its current assets during the most recently-completed fiscal year, please provide an explanation. Include the plan to rectify this situation.
  • 2.If your organization operated at a deficit during the most recently-completed fiscal year, please provide an explanation. Include the plan to rectify this situation. This question refers to the ratio between unrestricted revenues and unrestricted expenses.
  • F.PROJECT FUNDING

    1. Annual Budget Narrative:
      • a. Describe the details of the annual budget related to this project.
      • b. Explain the significance of the grant funding, if awarded, and the timeframe required.
      • c. Provide justification for the various items.
      • d. Explain whether grant funding is expected to leverage state, local or private funding sources. If yes, what amount of leverage will result through the funding of this proposal?
      • e. Explain whether any services proposed will be reimbursed through other means.
  • ADDITIONAL INFORMATION

    If there is any other relevant information you wish to provide in support of this request, please do so in this section in three hundred words or less. This information may include recent major accomplishments, uniqueness of board and/or staff, significant training opportunities for the board and/or staff, statistics or studies that demonstrate community need or program effectiveness, etc.

Please download and fill out the application below and include this as part of the application package.