WNY Trauma Collaborative
Donation Application

Name of Person/Organization requesting funds:

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Email

Point of Contact:

First Name

Last Name

The purpose of this request is:

Training

Professional networking

Scholarship

Community events associated with trauma collaborative mission

Other

Please provide a brief description of the event and how funds will be used:

What is the total budget of this project:

Requested amount of funding from Collaborative:

When is the funding needed:

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Date of the Event:

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I understand the following requirements of accepted funds from the WNY Trauma Collaborative:

1. All donations must be used to serve the Western NY community and be consistent with the trauma collaborative mission. 2. One request per year, unless additional funds are available. Organization/individual may make an additional request, but priority will rest with new applicant. Individuals who have not received funds previously will be considered first. 3. No funds may be used for events that are associated with political interest groups/parties. 4. We reserve the right to decline funding to any group we determine may undermine our mission or whose values are incongruent with the WNY trauma collaborative. We reserve the final right to fund or deny funding. 5. If funding is accepted, the funded will agree to provide a brief summary of the project or event, outcomes, number of people involved or in receipt of services and if available the program evaluation results. Pictures would be appreciated for the newsletter if available. This report must be submitted within 30 days of the funded event. Prior to event, but after acceptance for funding, funded must agree to the marketing of the event in the network and newsletter if applicable. 6. A W-9 form is required for tax purposes and must be received before funds will be disbursed.

I have read and agree to the above terms

Name

First Name

Last Name

Recent Monetary Awards:

April 2025: $1,500 for Gala Sponsorship: Honoring Clinicians of Color & Mental Health Professional Gala

June 2024: $1,525 for EMDR Basic Training

January 2023: $1,472.95 for EMDR Basic Training

September 2022: $1,800 for EMDR Basic Training

WNY Trauma Collaborative Donation Application

Recent Monetary Awards:

WNY Trauma Collaborative
Donation Application