Dream Fund Application | The Community Caring Collaborative

General Information

Provider Name*

Provider Email*

Provider Agency*

Provider Phone*

Client/Family Name*

Client/Family physical address*

Total dollar amount of request*

Ages of children must be 5 to 18 years old*

age of child 1	age of child 2	age of child 3

Request/Dream Information

History*

Please provide a brief family history and describe the dream

Resources available that currently support this dream:

(please be specific)

Scholarships	Equipment	Instructor/mentor/coach	Supplies	Transportation	Uniform	Other agency support	Others

How can the funding make a difference to the child(ren)?

(Please check all that apply)

Other

Please be specific

Please categorize your request according to the following areas

Supplies & equipment	Lessons (how many)	Camps/programs (dates)	Travel expenses (gas, meals, etc.)	Other expenses (please list below)

Additional Documentation

All requests must include supporting materials showing the cost of an estimate of the costs for this dream (e.g., an estimate, advertisement or brochure outlining the fees). If combining Dream Fund with other resources, you must fill out the Combined Funding Budget form below. Share any information you think the committee should know when making a determination.

Upload documents here

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, xls, docx, xlsx, , Max. file size: 32 MB.

Tips for uploading documents

If your client needs to submit a photo of a bill as part of the family's application, ask them to use the flash when taking the photo, and to email you the photo (large size is best) instead of texting you, if possible. Emailed photos are much clearer than texted photos which can be very hard to read.

Combined Funding Budget Form

Use only if you are combining your request from other sources. Only fill in the line items that apply to this request/need. Total costs must equal total funding. Do not fill this out if the Dream Fund is the only funding source for the request/need. To use this form, click on the link below and download to your computer and save. Fill out the form & download, then use the back arrow to return to the Dream Fund application. Upload your completed combined budget form with other supporting documentation in the space provided above.

Please click to complete the combined funding budget form.

Payment Information

must be completed

Vendor/Instructor/Organization

Address

Street Address Address Line 2 City State ZIP Code

Contact for follow-up Survey

Dream fund recipients are invited to complete and return a survey which will help the CCC capture the actual impact of the Dream Fund. The survey will be mailed out within 3 months after the funds have been disbursed.

Client/Family Signature*

please print your name - this will be your e-signature

Client/Family Email

Provider Signature*

Please print your name - this will be your e-signature

Date

Please Note:

A multi-agency committee of the Community Caring Collaborative reviews applicant information. The CCC encourages providers to arrange for necessary releases of information.

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