Charitable Foundation Request Committee Application Under $5,000

Thank you in advance for taking time to complete the application.

Normally, the request committee meets monthly and will get back to you within 4 weeks upon receipt of application.

All personal information collected in this application will be kept strictly confidential with the Rotary Request Committee Members.

Applications must be filled out and submitted by a qualified professional (Applicant) or member of the Rotary Club of Stratford on behalf of the client. Qualified professionals include, but may not be limited to: Social Worker, Faith leader, Case Worker, Health Care Worker or related. 

Initial of client’s first name:   e.g. Mary would be M   

  Initial of client’s last name: e.g. Smith would be S

 	
Client Town of Residence

Name of applicant: 

	Role: 
	
Name of organization: 

	Phone: 	
Email address:

Who referred you to apply to Rotary:

	

What is the total amount you require? Please attach quotes. 

	How much in total are you requesting from Rotary?
	
How much of the clients’ money will be contributed toward the total amount required?
	
Have you approached any other organizations for funding (Trillium, Ontario Works etc.)?  If so, who.

How much have other organizations committed?

Please provide a background of your situation and why you need Rotary’s financial help:

	

Date: ______________________________________

Signature: __________________________________

If you have any further questions please don’t hesitate to email request@rotarystratford.com Please email the completed form to request@rotarystratford.com