WNY Trauma Collaborative
Donation Application

PLEASE NOTE: our donation funds have been disbursed as of Feb 2023. We are currently not accepting applications for donations.

Name of Person/Organization requesting funds:

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Point of Contact:

First Name

Last Name

The purpose of this request is:

Training

Professional networking

Scholarship

Community events associated with trauma collaborative mission

Other

Please provide a brief description of the event and how funds will be used:

What is the total budget of this project:

Requested amount of funding from Collaborative:

When is the funding needed:

YYYY

Date of the Event:

YYYY

I understand the following requirements of accepted funds from the WNY Trauma Collaborative:

1. All donations must be used to serve the Western NY community and be consistent with the trauma collaborative mission. 2. One request per year, unless additional funds are available. Organization/individual may make an additional request, but priority will rest with new applicant. Individuals who have not received funds previously will be considered first. 3. No funds may be used for events that are associated with political interest groups/parties. 4. We reserve the right to decline funding to any group we determine may undermine our mission or whose values are incongruent with the WNY trauma collaborative. We reserve the final right to fund or deny funding. 5. If funding is accepted, the funded will agree to provide a brief summary of the project or event, outcomes, number of people involved or in receipt of services and if available the program evaluation results. Pictures would be appreciated for the newsletter if available. This report must be submitted within 30 days of the funded event. Prior to event, but after acceptance for funding, funded must agree to the marketing of the event in the network and newsletter if applicable.

I have read and agree to the above terms

Name

First Name

Last Name

WNY Trauma Collaborative Donation Application

WNY Trauma Collaborative
Donation Application