Fields marked with a * are required.
Organization or Agency Name: *
Organization's Email *
Organization's Phone *
Organization's EIN # *
Your First Name *
Your Last Name *
Title (How are you associated with the company)*
Your Phone *
Phone Type: *
CellLand Line
Accept Texts: *
YesNo
Amount of Grant Request *
Statement Of Needs
What are your emergency needs due to the coronavirus (COVID-19) pandemic? Please be specific. *
How has the COVID restrictions affected your organization? *
When did the concern begin? Have you maintained office hours since mid-March? *
Statement of Spending
What results do you expect to achieve if awarded an emergency relief grant? *
What expenses do you anticipate following the lift of COVID restrictions? Example: thermometers, sanitation gear, face masks for staff / clients, etc. *
What more do you wish to share with the COVID Committee?
Read & Initial
I agree to account for and return any amount of the unused / unaccounted for allocation.
By checking this, I understand that I have given the Adams County Community Foundation / United Way of Adams County permission to share my application with other committees so that I may beeligiblefor assistance beyond this selection committee.
e-Sign | Person Submitting Application:*
