2019 Amplify Grant

Date

Organization Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Where will your project have the greatest impact? (This will help us determine which RiseVT Program Manager contacts you.)

CONTACT PERSON

Name (First Last)

Email Address

Phone

FISCAL AGENT INFORMATION

(THE FISCAL AGENT IS WHO THE CHECK WILL BE MADE OUT TO AND WHO THE W9 SHOULD BE FROM.)

Name

Email Address

Phone

Federal Tax ID Number

Download a W-9 Tax Form

CLICK HERE

Upload Completed W-9 Form

PROGRAM/PROJECT DESCRIPTION

WE HIGHLY RECOMMEND THAT YOU COMPOSE THE BODY OF YOUR GRANT APPLICATION FIRST IN A DOCUMENT SUCH AS MS WORD, BEFORE CUTTING AND PASTING IT INTO THE ONLINE APPLICATION TEMPLATE

Project Name

Dollar amount requested

Summarize your program or project in two sentences

Provide a detailed description of your program or project.

Describe which strategies in the Recommended Community Strategies and Measurements to Prevent Obesity in the United States from the Centers for Disease Control and Prevention your project/program is most aligned with.

Find a summary of the CDC 24 strategies to reduce overweight and obesity here

Find full details of the strategies by reviewing the CDC Implementation and Measurement Guide here

Please provide a brief description of what RiseVT funding will pay for

Additional supporting documents (if needed)