Disaster Relief Application Form

Please use this application form to request funding for child care programs impacted by damage or disaster. You may mail, fax or email the completed form to us. Be sure to complete all questions.
I. Requester’s Contact Information
Name of organization:
County:
Physical Address:
Business Phone:
Mailing Address (if different):
Email:
Website (if applicable):
Contact person and title:
Cell Phone:
II. Amount of Grant Request
State amount that is being requested.
III. Purpose of Grant - Please limit your responses to 100 words
1. Briefly describe your child care program. Please include number of children served, age range of children served, geographic area served, days/hours of operation, primary sources of income, and any special services you may provide.
2. How has your program been impacted by a crisis and/or disaster? Please describe the specific crisis or disaster you have experienced.
3. What are your specific needs as a result of the crisis situation? Please explain how you will use the requested funds and your projected timeline for recovery. (Visit http://www.flchild.com/programs-services/forum-cares to view examples of the type of needs we can support).
4. Please include any other pertinent information you would like to share.
IV. Budget and Photo Evidence of Disaster
Please attach:
1. A proposed budget for the materials or services for which a grant is requested.
Max. file size: 16 GB.
2. Photos of the damage you have experienced.
Drop files here or

Max. file size: 16 GB.
Do you have any other sources of assistance to help you with this crisis?
- Insurance policies
- Other grants
- Community support, e.g., the Red Cross, the Salvation Army, etc.
- Other
Hidden
(please describe)
V. Applicant Background
1. Provide the date your program opened and number of years in continuous operation. Indicate your type of business; i.e., sole proprietorship, partnership or corporation.
2. Employer Identification Number:
3. Is your organization tax-exempt under Sections 501(c)(3) and/or 509(a) of the Internal Revenue Code?
[Tax-exemption is not required].
- Yes
- No
4. State the number of employees in your program:
Acknowledgement*
I acknowledge that this is a non-binding application and that the Children’s Forum makes all grant decisions at its sole discretion, subject to approved donor restrictions and applicable law. I certify that if grant funds are received, no individual, including myself, will receive any goods, services or other private benefit from the funds and that all funds will be used as described in this application.
- Yes
CAPTCHA

I. Requester’s Contact Information

II. Amount of Grant Request

III. Purpose of Grant - Please limit your responses to 100 words

IV. Budget and Photo Evidence of Disaster

V. Applicant Background