Grant Application · M. David Lewis MD Family Foundation

Youth SafetyLeadershipCharacter Opportunity for AllEvidence-Based PracticeMeasurable Outcomes

1 · Organization

Organization name *

Organization type

Tax status

EIN / tax ID (if applicable)

Website

City

State / province

Country

U.S. Based Mailing Address (where a grant check would be mailed) *We do not wire funds. Approved grants are paid by check, mailed to a U.S. based address.

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 Opportunity for All Evidence-Based Practice Measurable Outcomes Other

If "Other" — tell us how your project advances the Foundation's vision

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 · Photos (optional)

Share up to three photos of your organization's work — your team, your program in action, the people you serve. Photos are reviewed by the Foundation officers and are only published if you grant permission below.

Photo 1

Photo 2

Photo 3

Our organization grants the M. David Lewis MD Family Foundation permission to post these photos on its public website and materials. We confirm we hold the necessary rights and releases for the people shown.

5 · 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.

Keep this tracking code. With it and your contact email, you can check your status and add comments below at any time.