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Estimated time to complete, 30 minutes

This form is to request payment of the remaining 50% of the Ginny Gives Annual Grant. Once correctly submitted by the Host Community, and approved for payment by DSA, a check will be sent to the address on file within approximately 10 days.

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* 1. Enter name of Host Community (this will be the organization to whom the check is made payable):

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* 2. Enter the email for the original HOST COMMUNITY person designated in the application. If that person is now different (left their employer or changed their job role), please put the name and title of the new person, their phone number and their email here.

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* 3. Please enter the Ginny Gives Grant ID assigned by DSA at the time of approval (contained in approval email which went to the Host Community contact email provided in the application). If you do not have it, do NOT proceed. Send an email to admin@dementiasocIety.org, or call 1-800-DEMENTIA. Allow up to 3 business days for the response.

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* 4. Did you use a 3rd-party Program Provider, i.e., therapist, performer, singer, artist, supplier, etc., to deliver any or all of the Program elements? If so, please enter their name(s) and contact info here.

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* 5. In 300 words or less, please provide the QUANTITATIVE (numerical) outcomes of the grant-funded program/events. Example - Number of people (living with a Dementia diagnosis) that attended the Program (please also include any caregivers/partners in the total number); how much, how big, etc.?

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* 6. In 300 words or less, please provide the QUALITATIVE (non-numerical) outcomes of the grant-funded program/events. Example - Observations, interviews, satisfaction surveys? Please feel free to separately share with DSA any documents, materials and/or audio/videos pertinent to the outcomes of the grant to admin@dementiasociety.org. Alternately, you may share large files via a link to a folder on Dropbox or similar.

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* 7. In 10 words or less, how are the lives of your participants better as a result of your grant? Think of it as the headline to a story!

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* 8. In 100 words or less, please make comments on the Program, suggestions or provide an impact statement. Please tell us what you learned ...

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* 9. Please enter your full name here before you certify your actions in Question #6:

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* 10. I certify that any 3rd-party Program Provider(s) employed in the delivery of the Ginny Gives Grant ID specified herein, have been paid in full. DSA reserves the right to request/verify proof of payment.

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