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Organization Name
*
Also Known As: (if applicable)
Parent Organization(if applicable)
Organization Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Office Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Oganization Phone
*
Office Phone
Organization Email
*
Office Email
Tax ID Number
*
Total Annual Organizational Budget
*
Annual Revenues (actual/previous and current or budget)
*
Annual Expenses (actual/previous and current or budget)
*
Number of years in continous operation
*
Website
*
Facebook URL
Blog URL
Mission/Reason for Being
*
Present Scope of Programs and Services Offered
*
Number of Participants/clients served per year
*
Name of President/CEO/Executive Director
First
Middle
Last
Contact Person's Name
*
First
Middle
Last
Contact Person's Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Contact Person's Email
*
Implementer's Name
*
First
Middle
Last
Implementer's Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Implementer's Email
*
Description of Organization
*
Requested Amount
*
Total Program Budget (portion of budget supported by requested CCH Grant)
*
Target Population To Be Served
*
Target Geographic Area (by city or county)
*
Describe the unmet need and how it will be served
*
Describe the research that has been undertaken or the best practices analyzed and how these have impact program request
*
Describe the demographics of the target population you will serve
*
State 2-3 quantifiable objectives
*
Identify 1-2 measurable outcomes for each objective
*
Provide key components, action steps, and activities associated with each objective
*
What would success look like?
*
Provide summary of executive and program staff who will be responsible for leading and implementing the program. Include title, experience, program successes, and tenure with the organization.
*
Describe other organizations/programs in your area addressing the issue
*
Are there any other potential partners in this project? How have they been involved to date and how will they be involved in the implementation?
*
Annual financial statements or Audits - past two years (PDF Format)
*
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 512 MB.
501(c)3 IRS ruling letter (PDF Format)
*
Accepted file types: pdf, Max. file size: 512 MB.
Letter(s) of Support (PDF Format)
*
Drop files here or
Select files
Accepted file types: pdf, Max. file size: 512 MB.
List of Board of Directors and very brief description of their backgrounds
*
Accepted file types: pdf, docx, Max. file size: 512 MB.
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