Community Outreach Grants Application

Organizational Profile

Organization Name*

Address*

Street Address Address Line 2 City State ZIP Code

Website*

Organization Phone Number*

DBA/Alternate Name of Organization

EIN*

Please provide your organization’s purpose or Mission Statement.*

Is the Organization Tax Exempt?*

Yes

No

Your organization is not eligible for West Cancer Foundation funding. Please consider reapplying if your status changes. Return to our home page.

Primary Contact

Name*

First Last

Title*

Phone Number*

Mobile Phone*

Email Address*

Secondary Contact

Name

First Last

Title

Phone Number

Mobile Phone

Email Address

What is the primary focus of your organization?*

Please select based on your organization’s focus, not the focus of your event request. Please select from the below drop down.

What geographic area does your organization serve?

Please check all that apply.

Shelby County

DeSoto County

Crittendon County

Event Details

Event Name*

Please describe your event, how it will align with West Cancer Foundation’s mission and how grant funds will be used.*

Event Start Date*

Event End Date*

Event Start Time*

:

Event End Time*

:

Event Location*

Street Address Address Line 2 City State ZIP Code

Number of attendees expected*

Please enter a number greater than or equal to 1.

Amount Requested*

Please enter a number from 500 to 5000.

Please provide any additional information that may assist us in considering your event for grant funding.*

Please explain how West Cancer Foundation’s support will be acknowledged with this grant?

Organization Documents

Annual Report

Max. file size: 50 MB.

501(c)(3) Letter of Determination*

Max. file size: 50 MB.

Certificate of Insurance*

Max. file size: 50 MB.

Please upload the organization’s current year W-9 form*

Max. file size: 50 MB.

Board Roster*

Max. file size: 50 MB.

Program/Project Budget*

Max. file size: 50 MB.

Charitable Solicitation Certificate*

Max. file size: 50 MB.

Please upload any relevant sponsorship proposal documents.*

Drop files here or

Max. file size: 50 MB.

Organizational Profile

Primary Contact

Secondary Contact

Event Details

Organization Documents

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