Level 1 And Level 2 Grant Form

Healthy Choices Grant Application

Please fill out this application in its entirety.
Incomplete applications will not be accepted.
Please submit a completed application online.
We are unable to process applications sent via USPS.
You will be notified by e-mail of receipt of the application.
You will be notified of the grant status 15 days after the due date.
Successful grant recipients will receive a memorandum of understanding (MOU) to be returned within 10 days of receipt.
Rolling deadline for applications: April 15th, July 15th and October 15th

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Requesting Grant Type

Specify the grant you are applying:

If you are applying for a $1000 Individual Teacher Grant please specify the Grade Level:

If you are applying for a $2000 Campus Grade Level Grant please specify the Grade Level[s]:

Program Start Date:

Program End Date:

Applicant's Information

Applicant's Position

Name

Phone

Cell Phone

School Information

Type of Campus

School Address

State

Phone

School District

School Name

City

Zipcode

FAX

Website

Principal's Information

Principal's Name

Phone

Cell Phone

Organization's Information

Current Campus Enrollment / Demographic Breakdown of Student Population:

Type of Campus:

African American(%):

White(%):

Asian Pacific Islander(%):

Campus Enrollment:

Hispanic(%):

Native American(%):

Economically Disadvantaged(%):

Program Information Specific to this Grant Request

Program Name:

Number of Students:

Please describe the program, projected outcomes and plans for sustainability that you anticipate being able to achieve with this grant.

Line Item Budget

Program Equipment & Supplies($):

Incentives & Awards($):

Other($):

Total Amount to Support Projects($):

Meeting/Event Costs($):

Printing and Copying($):

Please provide an itemized list of your equipment, supplies, incentives, awards, meeting/event costs, printing/copying and other expenses. A detailed narrative is required.

10727

Level 1 And Level 2 Grant Form

Healthy Choices Grant Application

Requesting Grant Type

Applicant's Information

School Information

Principal's Information

Organization's Information

Current Campus Enrollment / Demographic Breakdown of Student Population:

Program Information Specific to this Grant Request

Line Item Budget

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