Emergency Grant Application 
 
This grant application is to be fully filled out and all questions answered or the grant will be sent back as incomplete.    
Attach additional pages where required.  
The request for an emergency grant must be submitted by the sitting
      District Governor within 30 days of the disaster. 
 
District applying for grant:  ______________________________________________ 
 
DistrictAddress:_________________________________________________________
 
District Governor’s name: _______________________________________________
Address: ______________________________________________________________ Phone:  _________________________________ Email:__________________________ 
 
Full description of the emergency and needs.  
Document the nature of the emergency by including media descriptions
       (Newspaper clips etc.).  
It is important to describe the needs as best as possible and how the funds
       will be spent.  (Attach additional page) 
 
Amount of grant requested ($2,500 max):  _______________ 
 
It is understood that a final report of grant completion must be submitted by the District Governor to the Secretary of the Foundation within 180 days of receipt of the grant funds. 
 
District Governor’s signature: ___________________________________________ 
 
Date:  _____________________ 
 
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Office use only Date received by office:  ___________________________