Grant Application · M. David Lewis MD Family Foundation

Youth SafetyLeadershipCharacter InclusionEvidence-Based PracticeMeasurable Outcomes

1 · Organization

Organization name *

Organization type

Tax status

EIN / tax ID (if applicable)

Website

City

State / province

Country

2 · Primary Contact

Full name *

Title / role

Email *

Phone

3 · Funding Request

Project title *

Amount requested (USD)

Total project budget (USD)

Foundation chaperone *

The Foundation officer sponsoring this application. Unsure? Ask your Foundation contact.

Second chaperone (optional)

If two officers are working together on this application.

Which Foundation priorities does this project advance?

Youth Safety Leadership Character Inclusion Evidence-Based Practice Measurable Outcomes

Project summary *

Population served

Number of youth reached

Geography served

Project start

Project end

Measurable outcomes — what will change, and how will you measure it?

Evidence base — research or results this approach is built on

Sustainability — how the work continues beyond this grant

Prior funding from this Foundation (if any)

Additional comments

4 · Certification I certify that I am authorized to submit this request on behalf of the organization named above, and that the information provided is accurate to the best of my knowledge.

Signed (type your full name) *

Application received — thank you.

Your request has been recorded and an executive summary has been sent to the Foundation officers for review.

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