Youth Grant Application
I. Contact Information
Organization/School/Club name: *
Your answer
Address: *
Your answer
Contact person: *
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Email: *
Your answer
Telephone: *
Please include area code
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Total project budget: *
Your answer
Amount requested (up to $500): *
Your answer
II. Assurance Statement
To be considered for funding by the Madison Civics Club, an organization must complete our application form and return it along with this signed assurance statement and a copy of the organization’s 501(c)(3) or equivalent determination letter from the IRS. For online application submission, type the name. If your organization or group is selected to receive a grant, we will need a signed copy of a PDF of the Assurance Statement that you can download from our website).

On behalf of the requesting organization, I hereby certify that the requested grants will be used for the purpose stated on the application form and will not be used in any program that otherwise discriminates on the basis of race, sex, religion, color creed, disability, sexual orientation, national origin, ancestry or age, or any other basis prohibited by applicable law.

Signature of authorized official: *
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Print name: *
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Date: *
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Name of requesting organization: *
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Funds must be used for the purpose proposed in the grant application or be returned to Madison Civics Club. *
Required
III. Proposal Description
Briefly outline your project and explain specifically how the requested funding will be used and what community needs will be addressed. *
You may email additional information about the project to youthgrants@madisoncivicsclub.org if desired.
Your answer
Who and approximately how many people will benefit from this funding? How will they benefit? *
Your answer
Please describe your program, including how your students are involved in civic and/or volunteer projects. *
Your answer
Please indicate the Madison Civics Club program that you are interested in having students attend. Describe how your group has been involved in this interest area as well as how students would benefit from hearing this speaker.
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How will the project acknowledge Madison Civics Club support? *
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Name of chaperone:
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Names of the two students attending (if known)
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Number of additional adult and student guests @$20.00 each:
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