2012 Beneficiary Application Form

There are 4 sections to the application. Click the expand button to view each section. Please answer all questions to the best of your ability.

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ORGANIZATION'S INFORMATION

ORGANIZATION SPECIFICS

Number of persons served annually*:
Percent Minority (optional): %
Percent Female (optional): %
Geographic areas served*:
 % Hartford  % New Haven  % Windham
 % Tolland  % Middlesex  % New London
 % Fairfield  % Outside CT  
 % other (please specify region)  
Number of employees*:  Full-time     Part-time    Volunteers
Specific purpose for which funds are requested*:
Is this is a new program?       Yes    No
Organization's Annual Budget
Total budget*:
Project's budget (if applicable):
2011 Salaries*:
Fiscal year*: to
Does your organization receive support from United Way, Combined Health,
Arts Council? Or other federated funds?
 Yes
 No
If yes, please explain amount.

NARRATIVE

Limit to three (4) pages. Use the headings, subheadings and numbers below. We understand that many of these questions will not apply to your organization. If a question does not apply to your organization, please indicate that with NA (Not Applicable).
1. Organizational Information
 
  1. Brief summary of organization's history, mission statement, vision statement and goals
  2. Description of current programs and accomplishments
  3. How this agency uses volunteers
2. Purpose of this request
 
  1. Description of how Team MAD's efforts will Make A Difference in your mission and vision statements.
    • Financially
    • Spreading the word of your organization's mission and vision to our runners and their supporters.
  2. Description of how the people expected to benefit from this project have been or will be involved in its development and implementation
  3. Description of how you plan to evaluate the success of the project, including outcomes and results
  4. Long-term strategies for funding this project
3. Budget/Financial Information (Provide the dates each document covers)
** If applicable we will be reviewing your Form 990.
 
  1. Budget for this program showing income and expenses
  2. Listing of the funding sources (foundations, corporations, others) solicited for this request for current year, and, if this is not a new project, for previous years (indicate the amounts requested and status of your proposal with each one)
  3. Most recent annual financial statement (audited, if available) and management letter (if available)
4. Other supporting materials
 
  1. Board membership list with names and affiliations
  2. Copy of IRS determination letter and/or explanation of your tax-exempt status
  3. Annual Report
5. Point of Contact
 
  1. Will the point of contact have the availability to work with Team MAD on a weekly basis (if needed)?
  2. Will there be an alternate point of contact?
6. Volunteers
 
  1. Please explain how you will provide Team MAD with volunteers to support our activities (for example: attending fundraising events, media events and some practices, hosting a water stop or cheering section at the marathon.
  2. As the chosen beneficiary, how can your organization assist us in recruiting runners?
  3. As the chosen beneficiary would any of your staffers/volunteers be interested in training with us and running in the marathon/half marathon or as part of a relay?
7. Why You?
 
Creating a strong connection between our runners and your organization is important to Team MAD. How do you envision our two groups working together and benefiting each other? Why is your organization the best choice for Team MAD in 2012?
Click here to Upload a File...      Microsoft Word, Adobe PDF, or Text formats accepted

DISCLAIMERS

We reserve the right to ask additional questions if needed after the application has been submitted that will be used in the decision making process. The decision of Team M.A.D.'s Board of Directors is final. Team M.A.D. reserves the right to select more than one charity to benefit for a given year.

We provide an organization with a one time donation where the amount of money will allow them to increase and expand their mission while promoting their cause to the better of our community.

At no time does Team M.A.D. promise any minimum amount and previous year's fundraising is not an indication of how much Team M.A.D. will raise in future years. It is solely based on the number of runners participating that year and their ability to reach or exceed their personal goals.

The total money raised by runners that is displayed on our website is not the total amount the beneficiary organization will receive as expenses and fees charged (i.e. PayPal or credit card processing fees) have not been taken into account. Corporate sponsorships will have a great impact on recovering the operational costs and allow us to increase the grant amount to the beneficiary organization.

It is understood that all qualifying applications will be considered for selection, but that does not mean your application and organization will be the one(s) selected. If selected, you understand Team M.A.D. will use your organization's name and logo in publications and promotional material.

Applications will not be considered for any year other than the year applied for. If you wish to be considered in a future year you must apply each year. If you have any questions during this process please contact Jody Barr at (860) 319-3636.

I have read this entire application including the disclaimer and answered every question truthfully. I understand any misrepresentation could result in an automatic withdrawal and agree to repay any donations Team M.A.D. has made to the organization I am representing, if this application is found to be misleading or deceitful in nature.
Agree     Disagree


FOR MORE INFORMATION CONTACT
Laura Hanson
Selection Committee Coordinator
E-mail: sc_coordinator@goteammad.org


Copyright © Team MAD, Inc 2011 All rights reserved.