Welfare Application

Name of Organization: __________________________________________________

Project Name: _________________________________________________________

Amount Requested: _____________________________________________________

Date Needed: __________________________________________________________

Address of Organization: _________________________________________________

Point of Contact: ________________________________________________________

POC Phone Number & Email: _____________________________________________

To whom should check be made payable: ____________________________________

Signature of Requestor: __________________________________________________

Signature of Approving Senior Official: _____________________________________

(I.e. school principal, president of organization)

Please itemize the amount requested. It must be clear how the money will be spent. (Forms will be returned if this information is missing. Receipts will need to be submitted)!

Is this an emergency request (Y/N)? If yes, please explain ________________________

_______________________________________________________________________

Available funds you currently have on record? _________________________________

Is your request eligible for financial support from appropriated and/or non-appropriated or PTA funds? Please explain: __________________________________________________________

________________________________________________________________________

What fundraising do you have planned to support yourself? _______________________

_______________________________________________________________________

_______________________________________________________________________

Briefly explain your proposed project. Include your objectives, the population to be served (number of persons, age) Be sure to indicate exactly what part of the project you hope BSCC will fund.

If BSCC does not award requested funds, what impact will this have on your organization/activity?