Special Grant Application Special Grant Application The Special Grant is intended to inspire collaboration amongst teachers to conduct larger-scale and longer-term projects to benefit their students. "*" indicates required fields School*Please selectAll FiveBelle Haven Elementary SchoolCesar Chavez Ravenswood Middle SchoolCostaño School of the ArtsEPA Academy High SchoolEPA Charter SchoolKIPP Esperanza High SchoolKIPP Valiant Community PrepLos Robles McNair AcademyOxford Day AcademyRavenswood Preschool Special EducationTide AcademyApplicant InformationPrimary Contact*The lead teacher or school staff member for the project. EPAK may contact you for additional information or updates on the grant project. First Last Position*School Email* Alternate Email* Phone*Disclosures To maintain our tax-exempt status EPAK is required to keep records of your relationship to EPAK board members, officers or donors.I am related to EPAK in this way:* I am an EPAK board member I am related to an EPAK board member, officer or donor none of the above 2nd Contact*In case the Primary Contact is unavailable. First Last 2nd Contact Position*2nd Contact Email* 2nd Contact Phone*Other teachers / staff*Please provide the names and contact info of all additional teachers / staff with an active role in the project.Project InformationProject Description/Objective*Please discuss your project’s mission – purpose, community, and desired impact. (200-350 words)Grades impacted*Select all that apply Pre-School TK/Kinder Elementary 1st-5th Middle 6th-8th High School 9th-12th Special Education Number of Students Impacted*Project Timeline*Please provide a timeline for your project. Briefly describe key milestones and estimated cost to achieve each milestone (100-350 words)Completion Date*Choose the date soon after the expected completion of your project. This will be the deadline to submit a Post-Project Report.choose a dateMarch 15June 15Sept 15December 15BudgetAdd as many lines as requiredLine Items Vendor Item Description Quantity Cost Sub-total Tax Shipping Total Actions Edit Delete There are no Line items. Add Line item Maximum number of line items reached. Total Amt RequestedThis field is hidden when viewing the formAdditional FundingDo you anticipate a recurring funding need for the project (e.g., additional funding needed beyond current request)?YesNoMaybeThis field is hidden when viewing the formPlease explainWhat are the potential additional costs beyond the current request for funding? How will these additional costs be covered?Funding Instructions*IMPORTANT: Special Grant payments will be made directly to the school. Please provide the name and info for the appropriate account. Electronic Transfer to the bank account below Check by mail to the address below Electronic Transfer to:To send an electronic transfer, the EPAK Treasurer will need the bank name, the name on the account and the routing information. Enter the info here or contact Ellen by Email: ellen@epak.org, or Phone: 650-704-3666. Bank Name on Account Routing # Account # Mailing Address for Check*Checks take up to 3 weeks and will arrive in an unmarked plain white envelope. Please watch your mail carefully if you choose this option. Name / School Street Address, Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip This field is hidden when viewing the formRequested date(s) of funding (allow at least 2-4 weeks)e.g. immediately upon grant approval, or specific date(s) for future purchasesCertification & AgreementI certify that I am directly responsible for the application and use of these funds. If I am awarded this grant, I agree to: Use these funds for the purpose I have stated. Request permission in writing before making any changes. Send any requested milestone reports and a completion report with scans of original receipts. Return unused funds to EPAK or request in writing before using them. Leave all equipment, supplies and materials purchased with these funds with my school or institution if I leave so that students will continue to have the benefit of this grant. Agreement* I have read and agree to the terms above NameThis field is for validation purposes and should be left unchanged.