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APPLICATION

Point of Contact Information

General Information

Letter of Recommendation

For the following questions, if an attachment will be provided, please write "Attached" in the form field.

Project Summary
In 300 words or less, provide an executive summary of the programing and/or projects that are most relevant to this year’s theme of health and wellness. This should show a proven record of achievement and extraordinary contributions towards betterment in the selected area. Please include:
     [1] The challenge the initiative is addressing
     [2] The innovative solution developed to address the issue

     [3] Other relevant data, if applicable (e.g., target demographic, milestones, objectives, partners, results, etc.)

Impact Statement 
Please indicate in 750 words or less how the organization or individual is improving health and wellness in the United States, particularly in regard to the following:
     [1] Breadth of impact, including geographic presence
     [2] Role as change agent
     [3] Collaboration among partners

     [4] Diversity of beneficiaries and Board/staff/volunteer representation, if applicable
     [5] Sustainability of the project.

Uploads

(Max 15MB each)

Recommendation Letter
Third party community member/organization who's benefited from the applicant’s work
IRS Determination Letter
Affirmation Letter also accepted
Tax Return (990 or 990-EZ)
Please provide from same year as audit/financial statements submitted
Financial Statement/Report
Please provide from same year as tax return submitted
Impact Statement
Please enter "Attached" in form field above if attaching document
Project Summary
Please enter "Attached" in form field above if attaching document
Other
Optional additional materials
Other
Optional additional materials

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You will receive confirmation via email that your application has been submitted. If you do not receive this confirmation within 24 hours please reach out to contact@chapmanprize.org

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