Grant Application

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Applicant Contact Information - Step 1 of 8

What type of Application is this? *

Individual Application
Group Application

Applicant Contact Information (the individual who will benefit from the request)

Name *

First

Last

Date of Birth *

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Layout

Phone *

Mobile

Child's Photo

Click or drag files to this area to upload. You can upload up to 3 files.

Group Application Contact Information

Name *

Contact Name *

Position

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Layout

Phone *

Mobile

Email *

Charitable Registration #

Are Audited Financial Statements Available? *

Parent/Guardian Contact Information

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Layout

Phone *

Mobile

Sponsor Contact Information

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Layout

Phone

Mobile

Relationship to Applicant

Grant Request Details

Cops for Kids does not pay for any additional warranties or service. These items are the responsibility of the parent. Funds will not be granted for items that have been purchased without prior approval.

Please describe the nature of the child's condition/situation *

Please provide a short personal history of the potential recipient *

Does the child currently receive funding through the At Home Program or other government agency? *

Do you have access to employer extended health care benefits? *

What other charities or government programs have you requested funds from, and what has been approved?

Amount Requested *

Please describe the specific purpose for the use of the funds: *

If approved, in what way would this grant application enhance the quality of the child’s life? *

Please explain why this creates a financial hardship for the family *

Please give any additional information which you think would be helpful to us in considering your request

Survey and Declaration

How did you hear about Cops for Kids? *

If other, please explain

Use of Personal Information

Cops for Kids relies on free public relations stories to encourage donations and to let people know we may be able to help them. By sharing your story, you helping us gain sponsorship, donations and helping other children.

While we respect your privacy, occasionally, we may be required to work with other professionals in order to coordinate funding on the child’s behalf. Do you agree to have us contact other professionals if required *

Would you agree to being presented Cops for Kids funding in a public setting such as a news conference? *

Would you agree to have your story (including photos) posted on the Cops for Kids website and used in press releases? *

Do you give Cops for Kids permission to work with health care professionals to confirm treatment details? *

If you would like to define limitations on how your story could be used by Cops for Kids, please detail here:

By submitting this form, I declare that all the information provided in the application is true and complete, and that any funds awarded will be used for the purpose(s) specified in the application or those funds will be returned to the Cops for Kids Charitable Foundation. The submission of this form also indicates the applicant is aware of the requirements of the Cops for Kids Charitable Foundation and that if any funds are awarded, the applicant agrees to abide by those requirements.

I declare that the information in this application is true and complete. I certify that if funds are awarded they will be used for the purposes described in this application.

Application requires recent photo of child and any requested supplementary information before it is submitted to the grants committee for approval.

Approved funding is valid for 1 year from time of approval with the exception of Medical Travel assistance which is valid for 2 years.
Two estimates may be required for major equipment and the quote will be to Cops for Kids Charitable Foundation.

Full financial disclosure may be required – it is the intent of Cops for Kids to assist lower income families.

Any equipment purchases are the property of Cops for Kids Charitable Foundation and in the event that the child no longer can use equipment Cops for Kids are to be contacted to ensure that the equipment can be reallocated to another child.

Parents/caregivers are responsible for additional warranties on electronics and equipment beyond the initial warranty offered by manufacture. It is the expectation of Cops for Kids that equipment is maintained and well cared for.

Re-entering your name and email address in the following boxes constitutes your signature.

Name *

Email *

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