Fill - Free fillable Optimist international Childhood Cancer Campaign Club and District Matching Grant Final Report PDF form

Optimist Clubs may use this application and attach additional pages as needed. Incomplete

applications will be returned to the contact person listed on this application for completion and will

not be reviewed. Applications should be submitted after Club/District has approved project. Clubs

may submit one CCC matching grant request per Optimist year.

These funds are intended to be used for Optimist Club projects and not to fund other Foundations and/or organization’s

programs. Projects can only be submitted for grant consideration once, regardless of whether they are ongoing projects.

Club/District Name: __________________ Number: ____________________________________________

Contact Person: _______________________________ Last Name: _______________________________

Mailing Address: _________________________________________________________________________

City: _________________________ State/Province: ____________________________________________

ZIP/Postal Code: ___________________ Country: ____________________________________________

Phone: ______________________________ E-mail: ____________________________________________

Please provide a brief description of the project below & anticipated cost of project:

________________________________________________________________________________________

Is project annual or ongoing? ________ If annual, how many years has it been run? ______

Date of Current Project ____________ Grant Amount Requested: $___________

How much Club/District money has been raised for the current project?______________

(Please do not list amount raised for project during total number of years it has been conducted).

What is the goal of the project?

________________________________________________________________________________________

Childhood Cancer Campaign

Club and District Matching Grant Applicaon

Why did your Club choose to allocate the funds in this way?

________________________________________________________________________________________

How will this goal be achieved?

________________________________________________________________________________________

How would this grant allow the project to achieve something not possible in the past?

________________________________________________________________________________________

How will the project impact children with cancer, their families and/or their caregivers?

________________________________________________________________________________________

How will this project impact the Childhood Cancer Campaign?

________________________________________________________________________________________

How did you hear about the CCC Matching grant program?

________________________________________________________________________________________

In order for this application to be complete the following documents must be attached:

1. A Project budget detailing project expenses and anticipated income sources.

2. A list of the members of your Board of Directors or District Officers including names & titles.

It is the decision of the Advisory Panel to grant either the full or a portion of the amount requested.

Only the amount requested or a portion of that amount will be granted. 50% of the amount granted

will be paid upon approval with 50% being paid after all paperwork and final report have been

received by Optimist International. Grant checks will be sent to the Club or District Treasurer. The

minimum amount grant requested is $250.00 with a maximum grant being $1,000.00. Projects

designed to fund other Foundations and/or organizations will not be considered. ALL

decisions of the Advisory Panel are final.

Send completed application to:

Optimist International, c/o CCC

4494 Lindell Blvd., St. Louis, MO 63108

Fax: (314) 371-6006 • ccc@optimist.org

ADVISORY PANEL APPROVAL

Date report received: _____________________________________________________________________

Conditions of approval (procedures to follow or specific instructions): ___________________________

________________________________________________________________________________________

PROJECT NAME: ________________________________________________________________________

PROJECT NUMBER: _____________________________________________________________________