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Good Samaritan Ministry Grant Application
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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number Maximum 20 characters Please enter a phone number.
- Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Type of Organization: (501(c)(3), Not Private Foundation: REQUIRED Please fill out this field. Please enter valid data.
- Agency Group Name REQUIRED Please fill out this field. Please enter valid data.
- EIN REQUIRED Please fill out this field. Please enter valid data.
- Year Founded REQUIRED Please fill out this field. Please enter valid data.
- President Name REQUIRED Please fill out this field. Please enter valid data.
- Contact Name (if different than above) Please enter valid data.
- What is your group's mission statement? REQUIRED Please fill out this field.
- Grant Request
- Amount Requested REQUIRED Please fill out this field. Please enter valid data.
- Project Start Date REQUIRED Please fill out this field. Please enter valid data.
- Project End Date REQUIRED Please fill out this field. Please enter valid data.
- Grantee has one month after the project is completed to submit a compliance report which must include receipts and documentation.
- What other funding has been received for this project? REQUIRED Please fill out this field.
- Provide a summary of how these grant funds will be used. Include how these funds will impact individuals and/or the community. REQUIRED Please fill out this field.
- After submitting this online form, please follow the steps below:
  
  Download the "Application Form Waiver" below. Please review and sign the waiver.
  
  Provide an operating budget for your project as well as certified financial statement (if possible, an audited statement) for your organization.
  
  Return the waiver, operating budget, and certified financial statement via email at GoodSams@saintlukeslidell.org.
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Documents
- Application Form Waiver

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