2. Directions: Please complete the application below in full. The electronic signature must be the applicant’s and it represents they attest to the information and intention to apply.

4. APPLICANT'S PERSONAL INFORMATION: (REQUIRED)
6. Last Name:*
7. First Name:*
8. Middle:
10. Organization Name*
11. Website
13. Street Address:*
15. City:*
16. State: *
17. Zip:*
19. Cell Phone #:*
20. Home Phone #:*
22. Email Address:*
24. Position Title*
25. Organization Established Date
    Organization Established Date
29. Program Details
31. Program Operation Dates*
    Program Operation Dates Start Date

    —

    Program Operation Dates End Date
33. Program Capacity*
34. Upload Program Capacity Document*
36. Program Cost*
37. Upload Program Cost Document
39. Education and Enrichment Quality*
40. Upload Education and Enrichment Quality Document*
42. Support Services*
43. Upload Support Services Document*
45. Additional Forms for Submission
    GRATUITY DISCLOSURE FORM
46. Completed Gratuity Disclosure Form*
48. 501c3 “Certification” Letter*
50. Additional Forms for Submission
    ANNUAL REPORTING FORM
51. Audit Letter/Annual Disclosure Form*
53. Charitable Contribution Letter*
55. Signature (Type name to electronically sign):*
56. Date:*
    Date:
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit Submit and Print

* indicates a required field