Application

JAMESTOWN SUBSTANCE ABUSE PREVENTION TASK FORCE

FUNDING REQUEST FORM




I. A. Date

   B. Name

   C. Postal Address




   D. Phone #

   E. Name and Address of Organization (if any) Seeking Funds



   F. Amount Requested




II A.Title Of Program



   B. Brief Description Of Program (include outline of Activities)












   C. Number of Estimated Participants and Age Group to be Served 




   D. Date(s) of Program

      Time

      Location



III. A. Purpose of Event or Program (What do you want to Achieve?) 












     B. Substance Abuse Prevention Component (Please describe)














IV.  A. Budget Outline of all Funds to be Used for this Particular Program
        (Please list all budgeted expenses with appropriate amounts.)
















     B. Other Sources from which Funding has been Requested and/or
        Obtained (Please list.)








Mail to: Task Force Coordinator
                P.O. Box 377
                Jamestown, RI 02835