Lamaze Mini-Grant Application Form

Please be sure you have reviewed the Grant Application Guidelines prior to completing this application! Note: Applicants are encouraged to use the Grant Application Guidelines as an outline to prepare online grant submissions in a word processing program and then paste into this form when all responses are complete.
Grant Application Type
Please Select One:*	Birth Network Community-Based Outreach
Applicant Contact Information
Organization Name:*
Contact Person:*
Mailing Address:*
City:*
State or Province:
Zip:*
Country:
Phone:*
E-mail:*
Official Recipient:*
Official recipient of grant funds, if awarded (check payee)
Lamaze Member Name:
Community-Based Outreach Mini-Grant applicants must be either: 1) Lamaze Certified Childbirth Educators who are current members of Lamaze International, or 2) Lamaze Approved Providers, currently in good standing. Birth Network Mini-Grant applicants may be members or non-members.
Lamaze Member ID:
Geographic Area Served:*
Please review the Grant Application Guidelines prior to completing the remaining sections! Proposal Summary
Please limit the Proposal Summary to 100 words:
Project Director and Collaborators
Please limit the Project Director and Collaborators to 250 words:
Project Beneficiaries
Please limit the Project Beneficiaries to 100 words:
Objectives, Activities and Timeline
Please limit the Objectives, Activities and Timeline to 500 words:
Evaluation Measures
Please limit the Evaluation Measures to 250 words:

Budget
Total budget for proposed project:
Amount requested from Lamaze:
Other sources of project support:
Project budget detail (justification):

Web Site, Promotional Brochures or Supplemental Material
Web Site:
Promotional Brochures or Supplemental Material:	(Please list links to or names of promotional brochures or other materials that are available upon request.)
For Birth Network Mini-Grant Applicants Only The below fields are required for all Birth Network Mini-Grant applications. Community-Based Outreach Mini-Grant applications may disregard this section.
Total annual budget:
List of officers and general description of the membership:	(Paste text into this field or paste a link to a Web site with a list of the birth network's officers and a description of the membership.)
Mission and governance:	(Please describe the birth network's mission, organization structure and decision making process.)



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For Birth Network Mini-Grant Applicants OnlyThe below fields are required for all Birth Network Mini-Grant applications.Community-Based Outreach Mini-Grant applications may disregard this section.

For Birth Network Mini-Grant Applicants Only
The below fields are required for all Birth Network Mini-Grant applications.
Community-Based Outreach Mini-Grant applications may disregard this section.