Requester Information

Requester Name*

First Last

Requester Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Relationship to Grantee

Additional Information

Have you been involved with any of the Foundation activities or Pucks for Autism?

Grant Information

Amount Requested*

Project Name*

Grant Purpose*

State the specific purpose of funds requested and the specific objectives you hope to achieve for the student(s) with these funds

Grant Activities*

What type of activities will be required to meet the objectives of this request?

Grant Budget*

Provide a budget of how funds will be spent. For programs or projects, provide a detailed budget and time frame of program or project. For equipment, provide a detailed description including suggested vendors.

Other Grants*

Yes
No

Are you aware of any other Foundation grant requests similar to this proposal?

Other Organizations*

Yes
No

Have requests been made to other organizations?

Other Organization Additional Info*

If organizations were contacted, list names and contacts of all organizations contacted. If no other organizations were contacted, explain why.

Grant Mission*

How does this grant request reflect your school’s mission or the SEDOL mission?

Grant Practices*

How does this grant request reflect sound instructional practices?

Grant Documentation*

How will documentation be presented to show the success of this request?

Project Sustainability*

How do you plan to sustain this program/project beyond SEDOL Foundation funding? (i.e. Add budget line item, apply to other Foundations, sale of merchandise, etc.)

Grantee Information

Group or Individual*

Group
Individual

Is this grant for a group or individual?

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact

Phone*

Group Additional Info*

State total number to be served, ethnic composition (i.e., 25% Caucasian, 15% Black, 60% Hispanic), age range and geographic location

School*

School and/or special education program attended by individual

Date of Birth*

Disability*

Additional Benefits*

Yes
No

Does the individual receive Medicaid or SSI?

School Lunch*

Yes
No

Does the individual qualify for free or reduced lunches at school?

Additional Information

Describe any unusual circumstances (i.e., medical costs, financial burdens, unemployment, family illnesses, etc.).

Annual Income*

$0 to $15,000
$15,001 to $25,000
$25,001 to $40,000
Over $40,001

Include all sources of income such as wages, public aid, child support, and other government assistance.

Number of Persons in Household*

Number of Adults*

Number of Children (Age 18 and Under)*

Verification

I understand that this application will be kept confidential and will be evaluated to determine whether the request qualifies for funding. I understand that funding is dependent on the availability of SEDOL Foundation funds. All of the above information is true and the information provided is complete.

Name of Requester*

First Last

Relationship to Grantee*

Date*

Supervisor Review*

Yes
No

My Sector Supervisor/Principal reviewed this request.

Additional Documents and Files

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, ppt, pptx, Max. file size: 50 MB.

Please upload any additional documents, brochures, and files that will assist in your application.

Pucks for Autism Grant Request Form

This form was designed to provide potential donors and the Grant Committee with required information concerning your request. Review the entire form and then fill it out in detail.

Requester Information

Grant Information

Grantee Information

Verification

Help Special Needs Children Reach Their Full Potential by Supporting the SEDOL Foundation.

Learn More

Contact Us