Request for Foundation Funds

NAME___________________________________CLUB_________________________

ADDRESS________________________________PHONE_______________________

YEARS IN 4-H as MEMBER/LEADER_________________DATE________________

TOTAL COST OF FUNCTION:__________ AMOUNT REQUESTED____________

BRIEFLY EXPLAIN THE REASON FOR REQUESTING FUNDS (include the 4-H activity involved; funds to be used only for 4-H activity/event):

EXPLAIN HOW YOU WILL BE ABLE TO “REPAY” THE FUNDS (example: in kind, presentations to other clubs/community groups, newsletter/newspaper articles, assisting with county 4-H activities, assisting with Foundation fundraisers, etc.):

COMMENTS FROM CLUB ORGANIZATIONAL LEADER (if applicant is 4-H member or project leader; please attach on separate sheet).

I agree to fulfill the terms outlined above. If I fail to do so, I agree to consider the funds a loan and repay the Foundation in full within 6 months.

___________________________ ______________ _________________________

Applicant’s Signature Date Parent/Guardian Signature

The above request is granted in the amount of $__________dependent upon the “repayment” of funds within six months of participation.

________As presented by applicant OR _______As amended below

Amendments by Foundation, if any:

* * * * * * * * * *

The above request is regretfully denied because:

____________________________ ______________

Foundation President Signature Date

Please return application form to: El Paso County 4-H Foundation, c/o Mary Gieseker, Treasurer, 1524 Zaiger Place, Colorado Springs, CO 80915.

Payment for approved requests will be made following the specific function or activity. El Paso County 4-H Foundation reserves the right to consider applications on an individual basis in emergency situations.