If your organization is interested in receiving a grant from Women United please complete this form. Your project/program must address issues that affect women and children. Organization Name Contact Person Name Contact Person Title Mailing Address Phone Number Email for Contact Person Website if applicable Amount Requested Describe the program for which you are seeking funding. What issue affecting women and/or children does your program address? How many individuals will be impacted by this funding? What outcomes will you use to measure success of this program? How will the funds specifically be used? What other funding sources do you have for this program? What is the sustainability of this program after the use of this grant?