Request Date: 

Requested for

(Agency/Organization & Program Name):

Name of Organization:  

Address:    

Agency/Organization Contact Person:

Name:

Phone Number:

E-mail:

Amount requested for this year:  

$

Amount awarded last year:

$

Program Description Summary e.g. Target clients (age, location, condition), program objective, method of service delivery, time in existence:

How does the agency/organization evaluate the impact of the program on its clients?

Briefly describe the program’s impact on its clients over the past two years:

How would a Church of the Mediator contribution be utilized?

If a Mediator Endowment grant was awarded in the past two years, please describe how this money was used:

Is additional information attached?

Will the agency/organization will provide a 250-500 word article for the Mediator newsletter describing the impact of this program on its clients?

Recommended by:  (Parishioner’s Name)

Parishioner Relationship to Organization: