CINCY YP & FUEL CINCINNATI SOCIAL INNOVATOR PITCH COMPETITION
$3,000 SOCIAL ENTREPRENEURSHIP PITCH COMPETITION
Applicant Organization (Legal Name)
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DBA/Previous Name (if changed) *
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Street Address *
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City *
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State *
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Zip *
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Website Address *
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Phone *
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Fax
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Executive Director/CEO *
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Executive Director/CEO Email Address *
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Name of person completing the application (if different)
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Phone of person completing the application (if different)
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Is Your Organization a 501(c)(3) charity? *
Legal Name (per IRS letter): *
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EIN # *
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Number of Full-Time Employees: *
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Number of Part-Time Employees: *
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Number of Full-Time Equivalents: *
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Number of Volunteers: *
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Current Operating Budget: $ *
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Audited? *
Audit Year
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Percent of Budget - Federal Funders: *
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Percent of Budget - Local Funders: *
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Percent of Budget - Earned Revenue: *
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Percent of Budget - Other (specify) *
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Program Budget, if applying for specific program within your organization: $
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Please List Your Major Funders: *
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Are you a chapter of a Regional or National Organization? *
Executive Director Electronic Signature
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Date
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Board President Electronic Signature
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Date
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Describe your organization in one sentence: *
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Briefly state your organization's Mission and Goals: *
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What is the problem or need that your organization is addressing? (Please include a definition of the population served, the geographic area served and number of individuals served annually. Consider impact of the social issue you address as well as the way it affects people, communities, etc.) *
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How is your approach to this social issue innovative? (What are you doing that is unique or different? Innovation can include applying a proven solution to a new problem, introducing a program to a new community, forging new partnerships/coalitions, etc.) *
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What results have you seen or do you expect from your social innovation? (Share measures and metrics you are using to monitor impact. Describe quantitative indications/results if possible.) *
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Who is the primary contact person for this application should we have questions? Please include phone and email. *
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I am an authorized representative of the organization completing this application. Please provide the name of the organization: *
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hereafter called "Applicant", agrees as follows:Applicant desires to participate in CINCY YP & FUEL CINCINNATI SOCIAL INNOVATOR PITCH COMPETITION Selection Process. In consideration for such participation, Applicant, on behalf of itself, and each of its employees, independent contractors, agents, attorneys, affiliates, partners, members, officers and managers, both in their personal and corporate capacities, and their heirs, personal representatives, successors and assign and as guardian or parent, if under 18, of any child (collectively, the "Releasing Parties"), does hereby voluntarily assume all risks of accident or damage to the person or property of the Applicant.The Releasing Parties hereby release and discharge CINCY YP & FUEL CINCINNATI SOCIAL INNOVATOR PITCH COMPETITION , Interact for Change, and their members, agents, employees, independent contractors, and volunteers (collectively, the "Released Parties") from any and all claims, suits, actions, causes of action. or demands, in law or equity, whether known or unknown, liquidated or unliquidated, for any damage or injury of any kind sustained by the Releasing Parties as part of any involvement with CINCY YP & FUEL CINCINNATI SOCIAL INNOVATOR PITCH COMPETITION or any related activities.The Applicant further agrees to defend, indemnify and forever hold harmless the Released Parties, from every claim, liability or demand of any kind however, but not limited to personal injury or damage. The Applicant acknowledges that the Released Parties are not employed by the Applicant and acknowledges and agrees that the Released Parties are not fiduciaries of Applicant and have no fiduciary duties or obligations to the Releasing Parties.
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First Name
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Last Name
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