Ronald McDonald House Charities of Metro St. Louis, Inc. Grant Application Form

Organizational Information:

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* Name of Organization

* Address

* City

* State

* Zip Code

* Contact Salutation:

Mr.

Mrs.

Ms.

* Contact Name

* Title

* E-Mail Address

* Specific Amount Requested from RMHC

Title of Project

RONALD McDONALD HOUSE CHARITIES INFORMATION

* Have you received RMHC or RMCC funding in the past? Yes or No.

* Please provide the address of the nearest McDonald's Restaurant in your organization's area:

* To what extent, if any, have you worked with a McDonald's representative:

0/150 words

Please complete the following if you are working with a McDonald's representative:

McDonald's Contact Individual:

Title/Position:

Address:

City:

State:

Zip Code:

Telephone Number(s):

(Please be assured that your request will receive the same consideration with or without an affiliation with McDonald's)

MISSION OR BRIEF HISTROY OF YOUR ORGANIZATION

* Mission or Brief History of Your Organization (100 word maximum):

0/100 words

* Has your organization been found to be liable in any legal proceeding or have any claims of liability been settled by your organization short of litigation, or are any liability claims pending against your organization?

Yes

No

*If yes, please explain:

0/150 words

PROJECT DESCRIPTION

* Brief Project Description and purpose of funds you are requesting from RMHC (150 word maximum):

0/150 words

* Anticipated date funds are needed:

* Location where funds will be used:

* Please check the description that best fits your program/project:

Target Population

* Total:

* Ages:

* Percentage of Male vs. Female

	Male
	Female

0/100 points

* Race: (Please insert percentages)

	African American
	Asian
	Caucasion
	Hispanic
	Native American
	Other

0/100 points

Total Itemized Project Budget:

* The specific amount requested from RMHC:

* List the items from the above budget to be purchased with RMHC funds:

Item: Cost:

0/500 characters

* Add the itemized budget, the total is:

Additional Funding

RMHC of Metro St. Louis evaluates each grant application and makes a final determination in one of four possible ways:

Approve the full amount as requested;
Approve partial funding for the program/project;
Table the decision to await further information and/or clarification, which will then be reviewed at an upcoming meeting of the Grant Review Committee; or
Deny the request

* If your organization receives partial funding for this project, will additional funding be sought from external sources, or will the organization make an internal funding commitment? Please Explain:

0/150 words

* What actions will your organization take if funding is denied from RMHC?

0/100 words

* If your organization receives funding from RMHC, will you allow us to use your organization's name and/or other details about your specific project in promotional material produced by RMHC (which may include but is not limited to in-store signage, tray liners, direct mail, radio, newspapers, TV, etc.)? Please answer Yes or No.

* Name and title of Authorized Individual:

* Date of Submission:

Please include the necessary attachments before you submit your application.
Click Browse, select your document, click upload. Thank you.

Cover Letter

IRS 501 (c) (3)

Most recent audited Financial Statements

Organizational Budget

A list of other donors which will be solicited to assist in your proposed project

If applicable, a letter of endorsement from a McDonald's Representive

If you would like to keep a copy of this for your records, please print this application now.

EXPLANATION OF PREVIOUS RMCC/RMHC FUNDING
(Please complete the following if you received RMHC funding in the past)

Project/program name, date received and amount of award.

What need was met or problem solved by this program/project.

0/150 words

What means were used to measure the overall effectivieness and/or success of the program/project:

0/150 words

Did the grant from RMCC/RMHC really make a difference - why or why not:

0/150 words

* Indicates Response Required