Today's Date: ______ORGANIZATION INFORMATION Name of organization: ______IRS tax ID number: ______

Street address: ______City: ______State: ______Zip Code: ______

Mailing Address (if different): ______City: ______State: ______Zip Code: ______Website: ______

CONTACT INFORMATION

Contact name: ___ Title: ______Email address: ______Phone Number: ______Fax Number: ______

PROGRAM INFORMATION

1. Describe the mission/purpose of your organization:

1Pioneer Grant Application 2. Summarize/List your current primary programs (overview):

3. Please indicate the grant amount you are applying for (not to exceed $5,000 and you must secure matching funding):

4. Being as specific as possible, please explain how these funds will be utilized:

2Pioneer Grant Application 5. Outline how you plan to implement the intended Adaptive program. Specifically address how you will utilize existing equipment and materials (or note equipment you’d like to purchase/build), how you will train your staff, and how you will promote the program:

6. Please indicate the population(s) you will be working with:

Amputee  Youth (17 and under)  Adults (18 and older) Autism  Youth (17 and under)  Adults (18 and older) Blind/Visually Impaired  Youth (17 and under)  Adults (18 and older) Cerebral Palsy  Youth (17 and under)  Adults (18 and older) Down Syndrome  Youth (17 and under)  Adults (18 and older) Dwarfism  Youth (17 and under)  Adults (18 and older) Multiple Sclerosis  Youth (17 and under)  Adults (18 and older) Spina Bifida  Youth (17 and under)  Adults (18 and older) Spinal Cord Injury  Youth (17 and under)  Adults (18 and older) Post-Traumatic Stress Disorder  Youth (17 and under)  Adults (18 and older) Traumatic Brain Injury  Youth (17 and under)  Adults (18 and older) Veterans  Adults (18 and older) Other (please specify youth and/or adult): 3Pioneer Grant Application 7. List/Attach the name(s) and member number(s) of US Sailing Small Boat Level 1 and/or Basic Keelboat certified Instructors* in the center. At least one certified Instructor must be employed or insured by the center. List any additional instructors on a separate piece of paper entitled Additional Program Staff.

Indicate any additional US Sailing Certifications that your instructors have (example: Level 1 Instructor Trainer, Powerboat Instructor, etc.) and indicate what classes they teach in your organization.

Instructor Name Membership # Any Additional US Sailing Classes taught Certifications

* A current US Sailing instructor is defined as one who has taken and passed the Small Boat Level 1 or Basic Keelboat Instructor Course, their membership and instructor status are current (note: Instructors need to recertify their instructor certifications every three years to remain current).

8. Summarize how you will provide measurable results for the Adaptive program:

4Pioneer Grant Application 9. Include a preliminary budget for the indicated program:

10. Please indicate any funding you have secured to date and its origin:

11. Please indicate how your prospective programming will align with the goals of growing adaptive sailing in your community:

5Pioneer Grant Application Statement of Understanding I understand that submission of this application is not a guarantee of acceptance and that exclusion of any components my exclude me from consideration. I also agree that if my organization is chosen as a grant recipient, we will be required to provide US Sailing with copies of all print and electronic materials associated with the impacted program, including marketing materials, curriculums, lessons plans or other, similar, documentation. It is understood that this documentation may be made available to other US Sailing member organizations at no charge via a print or electronic medium. Credit will be provided to your organization for any materials that are made available through US Sailing.

Printed Name: Signature:

Title: Date:

Please mail the completed grant application and any supporting documentation to:

6Pioneer Grant Application US Sailing-Pioneer Grants c/o Stuart Gilfillen 15 Maritime Drive Portsmouth, RI 02871

or submit it via fax to 401.683.0840

7Pioneer Grant Application