Preview- Ann Bancroft Grant Application, Fall 2023

Applicant Information

Please include the information below for the applicant (girl) applying for the grant.

Grant Year

______________________ (2023)

Applicant First Name

______________________

Applicant Last Name

______________________

Applicant Home Street Address

______________________

Applicant Home City

Applicant Home State (MN)

Applicant Home Zip Code

______________________

Applicant Home County

Applicant Phone Number

______________________

Applicant Email Address

______________________

Applicant Date of Birth

______________________

Applicant Current Age

Applicant Current Grade

Applicant School

If school is not on the list above, please indicate school here:

______________________

School City

______________________

Applicant Race/Ethnicity

You may select more than one response.

□ American Indian or Alaska Native

□ Asian

□ Black or African American

□ Hispanic

□ Native Hawaiian or Other Pacific Islander

□ White

□ Choose not to share

□ Other __________________________

How did you hear about this grant opportunity?

○ ABF E-Newsletter

○ ABF Staff Member

○ ABF Website

○ Coach/Group Leader

○ Former Grant Recipient

○ Friend/Family ○ Online Search

○ School/Teacher

○ Social Media

○ Television/Radio

○ Other, please specify... __________________________

If you were referred by someone or by another organization, would you please provide the organization’s name and/or the individual’s name

Parent and Guardian Information

Parent/Guardian First Name

______________________

Parent/Guardian Last Name

______________________

Parent/Guardian Home Street Address

______________________

Parent/Guardian Home City

Parent/Guardian Home City if not Minnesota

______________________

Home County (if home address is MN)

Parent/Guardian Home State (MN)

Parent/Guardian Home Zip Code

______________________

Parent/Guardian Email Address

______________________

Parent/Guardian Phone Number

Mentor Information

Form for "Mentor Information"

Reminder: An ABF grant mentor cannot be a family member (parent, guardian, brother, sister, aunt, uncle, grandmother, grandfather), the activity provider, or an employee of the activity provider.

Mentor First Name

______________________

Mentor Last Name

______________________

Mentor Home Street Address

______________________

Mentor Home City

Mentor Home City if not Minnesota

______________________

Home County if home address is MN

Mentor Home State

Mentor Home Zip Code

______________________

Mentor Email Address

Will be used for grant notification email

______________________ Mentor Phone Number

______________________

Mentor relationship to mentee

Grant Activity Information

Grant Activity Description (5 words or less)

______________________

Grant Request Amount ($1000 maximum)

______________________

Grant Request Itemized Budget

Please include a cost breakdown of how the $1000 will be allocated including any equipment or technology costs. Must include an activity + equipment. If the activity is free of charge, but requires technology or equipment, we encourage girls to apply. Technology expenses will be reimbursed after a receipt is provided.

Total Cost of Activity

______________________

Type of Activity

□ Arts/Music

□ Culture/Language

□ Horse Riding

□ Leadership/Education

□ STEM

□ Travel

□ Dance/Ballet

□ Basketball

□ Cheerleading

□ Cross Country/Track

□ Figure Skating/Hockey

□ Gymnastics

□ Outdoors

□ Soccer

□ Softball

□ Volleyball

□ Sports: Other

□ Sports: Other, please specify... __________________________

□ Other, please specify... __________________________

Activity Start Date (approximate)

______________________

Activity End Date (approximate)

Activity must be complete on or before April 1, 2024

______________________

Activity Provider Name (as would be written on the check)

______________________

Activity Provider Contact Name (first and last)

______________________

Activity Provider Street Address (where check will be mailed to)

______________________

Activity Provider City

______________________

Activity Provider State

______________________

Activity Provider Zip Code

______________________

Activity Provider Email Address

______________________

Activity Provider Phone Number

______________________

Activity Provider Website

Applicant Responses

This section must be completed fully by the applicant herself to be considered by the selection panel. Please answer the following questions clearly and thoroughly in your own words. The more detail you can share about your activity and dream, the more we will be able to understand what you hope to be able to achieve with this grant. If the applicant is not able to type, the mentor or parent/guardian may type the applicant’s responses for her.

1. What activity will you participate in with this grant and why is it important to you?

2. Tell us about a big, bold dream that you have. How do you think this activity will help you accomplish and achieve your goals or dream(s)?

3. What do you hope to learn or discover about yourself through this activity?

4. Describe something about yourself that you are proud of and why that matters to you.

5. What is the applicant's relationship with the mentor? How is your mentor helping you with your application and how will they help you with your grant activity?

6. Are you raising additional money to make participation in this activity possible? If so, how?

7. Please provide any other information you think is important for us to know about you or your application.

Mentor Responses

Mentors, please answer the following questions on behalf of your mentee. In addition to reading the responses of your mentee, your answers below will help us understand how this grant will help your mentee have a chance to live her dream and reach her full potential. Reminder: Mentors cannot be an immediate family member (not the girl’s parent, guardian, brother, sister, aunt, or uncle), the activity provider, or an employee of the activity provider.

1. What is your relationship to your mentee? How and when did you meet?

_____________________________________________________________

2. Why do you feel that this experience will be important to this girl?

_____________________________________________________________

3. What criteria do you use to assess the need of this girl? For example, is there a financial need, any personal challenges, or other barriers to her ability to pursue her goals or dream(s)?

_____________________________________________________________

4. Why is this a good time for this girl to participate in this specific activity?

_____________________________________________________________

5. What do you hope your mentee will learn or accomplish from this experience?

_____________________________________________________________

6. How will you support your mentee throughout and after her activity?

_____________________________________________________________

_____________________________________________________________ _____________________________________________________________

7. Is there anything else you would like the share?

_____________________________________________________________

Applicant & Parent/Guardian Signature

Media Authorization and Consent:Grant recipients of the Ann Bancroft Foundation (ABF) grant programs can be featured in public relations and marketing materials, including but not limited to: press releases, annual reports, newsletters, websites, social media, brochures, letters, slide/PowerPoint presentations, video presentations and photo displays to show the accomplishments of our grant recipients, raise awareness of ABF grant programs, help fundraise for ABF, and show the long-term impact of the ABF grant programs. Information such as grantee interviews, quotes, photos, videos, written materials, and social media content may be used by ABF to further the mission of the Foundation and/or shared with the general public (school officials, media, newsletters, publications, web site), content developers (photographers, writers, designers who help ABF develop materials), distribution agents (printing companies and mailing services engaged by ABF), and potential donors to ABF. ABF also welcomes usergenerated content that can be shared and re-used by ABF to show the grant experience, first-hand. Content includes, but is not limited to: grantee/mentor/parent/guardian social media posts that tag or mention ABF, articles or blog posts written by grantee/mentor/parent/guardian, and videos or newspaper articles that feature an ABF grantee/mentor/parent/guardian. I understand that any information, photographs, videotapes or recordings sent with my grant materials remain the property of ABF. I discharge the Ann Bancroft Foundation from claims, causes of action, and liabilities arising from or in connection to the use of my materials.

Date

_______/____/____(YYYY/MM/DD)

Date

_______/____/____(YYYY/MM/DD)

Mentor Signature

Media Authorization and Consent: Grant recipients of the Ann Bancroft Foundation (ABF) grant programs can be featured in public relations and marketing materials, including but not limited to: press releases, annual reports, newsletters, websites, social media, brochures, letters, slide/PowerPoint presentations, video presentations and photo displays to show the accomplishments of our grant recipients, raise awareness of ABF grant programs, help fundraise for ABF, and show the long-term impact of the ABF grant programs. Information such as grantee interviews, quotes, photos, videos, written materials, and social media content may be used by ABF to further the mission of the Foundation and/or shared with the general public (school officials, media, newsletters, publications, web site), content developers (photographers, writers, designers who help ABF develop materials), distribution agents (printing companies and mailing services engaged by ABF), and potential donors to ABF. ABF also welcomes user-generated content that can be shared and re-used by ABF to show the grant experience, first-hand. Content includes, but is not limited to: grantee/mentor/parent/guardian social media posts that tag or mention ABF, articles or blog posts written by grantee/mentor/parent/guardian, and videos or newspaper articles that feature an ABF grantee/mentor/parent/guardian. I understand that any information, photographs, videotapes or recordings sent with my grant materials remain the property of ABF. I discharge the Ann Bancroft Foundation from claims, causes of action, and liabilities arising from or in connection to the use of my materials. Date _______/____/____(YYYY/MM/DD)