Application Form Step 1 of 2 50% Is your organization eligible for funding?Please answer these 3 questions to find out if your organization might be eligible for funding.Are you a tax-exempt organization under section 501(c)(3) of the Internal Revenue Code?*YesNoDo your operations and programs/events take place in the United States?*YesNoDoes your organization primarily serve individuals with physical disabilities?*YesNoWe are sorry, but your organization is not eligible for funding. If you have any questions, you are welcome to contact us for more information: firstname.lastname@example.org.Congratulations, you are eligible for funding! Please proceed to the application by clicking Next Save and Continue Later Organization InformationOrganization Name*Tax ID Number (EIN)*Website* Please make sure to enter http:// before your website address.Address* Street Address City State / Province / Region ZIP / Postal Code Contact Name*Title*Phone Number*Fax Number*Email Address* Required AttachmentsApplications that do not include these attachments will not be accepted. If your files are very large (over 10MB), please email them to us separately at email@example.com and leave these fields blank.Project Expense Report*An itemized project expense report describing detailed budget information for your program/event that clearly specifies which line items are expected to be cash expenses and which items will be provided through in-kind contributions.Project Expense Report Checkbox I will email my Project Expense Report IRS Determination Letter*IRS Determination Letter establishing your organization as tax-exempt under section 501(c)(3) of the Internal Revenue Code. IRS Determination Letter Checkbox I will email my IRS Determination Letter Annual Report*If it is longer than 5 pages, please mail 5 copies to us within 5 days of application deadline to this address: PO Box 63 Rockaway, NJ 07866Annual Report Checkbox I will mail my Annual Report Additional attachmentsPlease attach any supplemental attachments you feel Dralla Foundation needs that is not provided in this application. Drop files here or Grant InformationProposal Title*Event Date*Acknowledgement of award date* Please check here to acknowledge that you are aware all awards will be considered for events that fall between the dates of June 1, 2020 and May 31, 20201 Is this event open to the public?*YesNoShould you receive an award, do we have permission to display event date and location details on our website?*YesNoPlease provide a brief description of the event that can be used for promoting it, as well as the date, time, and location (If it will be open to the public.)*Please give a brief explanation as to why you would prefer we do not display event description on our website.*Should you receive an award, do we have permission to promote your event on our social media?*YesNoPlease give a brief explanation as to why you would prefer we do not promote your event on social media:*1. Who is served by this program/event?*Please select all that apply. Children and teens with physical challenges Adults with physical challenges Other Please describe*2. What are the types of physical challenges your organization serves?*Please select one of the following choices (Must include mobility impairment):Mobility impairmentMobility and cognitive impairment combination3. What is the expected duration of the program/event for which funds are being requested?*DaysWeeksOther 4. Total population of those in the targeted community currently SEEKING the services of THIS program/event:*5. Number of individuals expected to be SERVED through THIS program/event:*Please enter a value greater than or equal to 0.(Must be equal to or less than the answer provided in question 4)6. Product and/or services to be provided by THIS program/event:*Please select one of the following choices:Health/medical EquipmentSocial Services and SupportBoth Health/Medical Equipment AND Services/Support7. What is the objective of your event?*Make it possible for participants to take part in an activity they would never otherwise be able to participate in.Teach participants a new activity they would never otherwise learn or be able to participate in.8. Concept Originality*Please select one of the following choices:New to community to be servedExisting to community to be served9. Number of organizations in the community serving the same need:*Please select one of the following choices:NoneOne or more10. For how many years has this organization been serving the needs of the physically challenged?*Please enter a value greater than or equal to 0.11. Has your organization been previously funded by Dralla?*YesNoPreviously Funded Years/Amounts*YearAmount 12. Amount requested from Dralla*Please enter a value greater than or equal to 0.13. Percentage of THIS program/event’s budget being requested from Dralla:*Please enter a value between 0 and 100.14. What other resources and/or funding are you planning to utilize towards this program/event?*For example, list all in kind donations, volunteers, other grant applications, corporate sponsorships, etc. Please be as detailed as possible.15. Proprietary/Confidential Information*NO – Proposal does not contain proprietary information, unrestricted distribution authorizedYES – Proposal contains proprietary information, restrict distribution and disclosure16. Briefly state the mission of your organization*17. Specifically, how will this year’s requested Dralla funds be utilized?*18. How have the participants been selected?*19. What is the fee charged to participants?*20. Why is your organization best suited to provide this program/event?*21. Please describe in detail how your program/event supports children, adults and families affected <em>specifically</em> by PHYSICAL challenges?*22. Dralla Foundation would like to give an opportunity for individuals with physical challenges to have an unforgettable day. How will your program/event enable them to have an unforgettable day?*Terms & ConditionsPlease check each box in acknowledgement of the following conditions:Completed Grant Report*As a condition of accepting an award, I hereby acknowledge that I will provide a completed Grant Report and will supply testimonials and photos/videos from the specific program/event Dralla Foundation is funding within one month completion of project. I agree Agree to display Dralla sign*As a condition of accepting an award, I will display the Dralla sign at our program/event, which will be provided to us. I will also include the Dralla logo in any literature or marketing materials (printed, e-mail, website or social media) promoting the event. (Dralla Foundation’s purpose in your use of our logo is to spread awareness of our grant program through the community so that we can continue to serve more organizations.) I agree Agree that information is accurate*I attest that the information contained in this application is accurate and that I have the authority to solicit funds on behalf of this organization. I agree Website LinkWould you be willing to link to allardusa.com on your website?*Dralla Foundation was founded by Peter Allard, President of Allard USA, manufacturer of a range of orthopedic devices designed to improve physical function and enhance the quality of life for individuals with physical challenges. Should you be awarded a grant, would you be willing to add a link on your website to www.allardusa.com to make it easier for people you serve to find a solution to foot drop? (Note: This is not conditional to being awarded a grant).Yes, we would be willing to place the link on our website.No, we would not be willing to place the link on our website at this time.Proposed Budget SummaryCompetition for funding is high, so please complete this information to the best of your ability. It factors greatly into your consideration for funding. Proposal Title*Please do not leave any information blank. If there is an area listed below where you are not requesting funding, please enter N/A.Salaries/Wages*Total Program CostRequested Dralla Portion Equipment*Total Program CostRequested Dralla Portion Administrative Expenses*Total Program CostRequested Dralla Portion Supplies and other expenses*Total Program CostRequested Dralla Portion Total Program/Event Budget*Total Program CostRequested Dralla Portion Question 12* and the Total Requested Dralla portion of the Proposed Budget Summary should match.PhoneThis field is for validation purposes and should be left unchanged. 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