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Please specify what attempts were made to obtain funding from other sources prior to applying for this grant.*

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Enter EACH Child/Youth's Info *Required

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Youth Initials	Date of Birth	Actions

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Youth Initials Date of Birth
Name of Employer/Affiliation*
You must be a CASA volunteer, a paid employee at OPA, OCS, tribal entity, or a paid employee or volunteer at a child advocacy organization in order to apply for a grant.
Requester's Name*
First Last
Requester's Email*
Requester's Phone*
For camps, when direct pay is requested, provide business name and mailing address.
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Court Case Numbers for all children (or # of children if this Event or Group project)*
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Child's Name*
First Last
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Child's Age*
Requestor's Mailing Address (for reimbursement)
Amount requested per child/youth or total request for the family.*
** Please note that funds must be encumbered by August 15. Any funds not spent or encumbered by that date will automatically lapse and the grant will close.
Description of Need*
Is this request for an electronic device?*
- No
- Yes
A completed Family Placement Agreement is required for electronic devices. See FACC's main grants page for a link to the form. You may upload the completed Family Placement Agreement here.
Max. file size: 50 MB.
Acknowledgment of review of FACC grant policy*
Type your initials to acknowledge that you've read and agree with FACC grant policy: View Grant Policy
Date*
MM slash DD slash YYYY
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Teresa K