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PAY BACK Application

(Phoenix Assisting Youth By Advancing Civic Kindness)

Complete the application form and use the submit button or mail to the address noted below.

*Your Name:

*Home Address:

*City:     *Zip Code:     *Grade Level:

*Phone:     E-mail:

*Name of adult sponsor:

*Club/Organization (checks will be made payable to this group):

*Club/Organization Address:

*City:     *Zip Code:

*Phone:     Fax:     E-mail:

*Project Name:

*Date of project:

*Project Location (including address and cross-streets, or neighborhood):

*Number of youth participating:

*Dollar Amount Requested:

Please answer the questions below. The answers to these questions should not TOTAL more than two pages (this does not include the information above or the budget).

1. * Explain your project fully.

2. * Why did you choose this project?

3. * Who/what will benefit from this project? Specifically, how will the city of Phoenix benefit from this project?

What is your project's proposed budget?

Here is a sample budget (please use this format):

Sample Budget
Item Cost per item (store) Number of items Total
Flyers to advertise event 10 cents per copy 100 flyers $10
Worker's gloves $5 per pair 20 pairs $100
Garbage Bags $5 per box 2 $10
Total Dollar Amount Requested $120*

Proposed Budget*
Item Cost per item (store) Number of items Total
Total Dollar Amount Requested **

Total amount of Project:

* Required fields
**This number should match the Dollar Amount of Money Requested line
.

Return to:
City of Phoenix
Youth and Education Commission
200 W. Washington, 12th Floor
Phoenix, Arizona 85003
(602) 495-0314 Fax: (602) 534-3644

Before you submit this form, we would like you to be aware of the city's policy on the use of its e-mail systems. The policy states that the e-mail message you are about to send: (1) is subject to public disclosure under the Public Records Law, (2) is not private or confidential and (3) is retained for one month.

Last Modified on 09/17/2008 12:58:45