Application for Funding


Board of Directors: Please provide Name, Email, Telephone for each member.

Does your agency comply with the requirement that recipients of services not be discriminated against for any reason, including, but not limited to race, family status, color, religion, national origin, handicap or age?
Has there been a change in your tax exempt status?
Are you a ministry of a religious organization? If, so please list name, address, and phone of contact organization.
If Applicable
What are your hours of operation?
If available, please list a number besides the office where the director can be reached after hours.
How many volunteers do you have?
How often do you have volunteer and board training?
What services do you provide?
Do you acknowledge that your agency is not associated with abortion activities, including counseling for or referrals to abortion clinics, providing medical abortion-related procedures, or pro-abortion advertising?
Use space below to include any additional information you would like to share about your agency.