Project Name: _______________________________________________________________________

Community / School / Organization Information:

Name:______________________________________________________________________________

Executive Dir./CEO/President:__________________________________________________________

Program Name (if applicable):___________________________________________________________

Address:____________________________________________________________________________

City: ___________________________________Zip:_________________________________________

Phone #: ____________________________________Fax #:__________________________________

E-Mail Address:______________________________________________________________________

Project Contact Information (required if different than above):

Name:______________________________________________________________________________

Program Name (if applicable):___________________________________________________________

Address:____________________________________________________________________________

City: ___________________________________Zip:_________________________________________

Phone #: ____________________________________Fax #:__________________________________

E-Mail Address:______________________________________________________________________

Fiscal Contact Information (required if different than above):
Organization Name:___________________________________________________________________

Fiscal Contact Name: _________________________________________________________________

Address:____________________________________________________________________________

City: ________________________ Zip:________________________________________

Phone #: ____________________________ Fax #: ______________________________

Project or Event Name (required):

Starting Date: ________________________ Ending Date: _________________________

Please indicate if these are known or anticipated project dates (Check One):
Known: ____________________Anticipated:__________________

Narrative Information (1-2 attachment):

1. Summary Statement of Project or Event (Include: Who, What, Where, When & How Many Involved) 2. Provide the following required information:

a. Describe how youth are involved in the planning of this project or event. b. Describe how youth will be involved in the implementation of this project or event. c. Describe the role of the adult liaison / advisor to this project or event. d. Describe how the youth and the community will benefit from this project or event. e. Which of the Developmental Assets will be addressed through the efforts of this project or event? f. How will this project or event be supported by other entities?