Survey - Breaking Barriers Partner Application

Breaking Barriers Partner Application

Question - Required - Name of Organization:

Question - Required - Year Established:

Question - Required - Tax ID Number:

Provide your organization's Contact Person. (This is who we will contact upon reviewing your application)


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Phone Number: Required
	Remember me. What's this?

Question - Required - Contact Person's Title

Question - Not Required - Organization's Website Address (if applicable)

Question - Not Required - Organization's Facebook Page (if applicable)

Question - Required - Organization's Mission:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Strategic Priorities

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - How many people are served through this nonprofit?

Question - Required - How do you plan to use the fund from BB/BF?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Required - How did you hear about BB/BF

Question - Required - Beneficiary Category (Check All that Apply)
Please make at least 1 selection from the choices below.

	Wellness - Nutrition
	Wellness - Self Injury
	Wellness - Mental Health
	Wellness - Addiction
	Wellness - Eating Disorders
	Wellness - Body Image
	Wellness - Obesity
	Health - Cancer
	Health - Diabetes
	Health - Asthma
	Health - Autism
	Health - Cystic Fibrosis
	Education - Truancy
	Education - Literacy
	Education - Reading Readiness
	Education - ADHD
	Education - Dyslexia
	Education - School Violence
	Education - School Resources (equipment and books)
	Education - Enrichment Education (arts and electives)
	Education - Summer Learning Opportunities
	Education - Hunger in School
	Education - Tutoring Needs
	Character and Leadership Development
	Esnvironment/Physical Needs - Homelessness
	Environment/Physical Needs - High Mobility
	Environment/Physical Needs - Child Abuse/Neglect
	Environment/Physical Needs - Domestic Violence
	Environment/Physical Needs - Medical Needs
	Environment/Physical Needs - Hunger
	Environment/Physical Needs - Poverty
	Social/Emotional - Peer Issues
	Social/Emotional - Bullying
	Social/Emotional - Social Adjustments
	Social/Emotional - Gangs
	Social/Emotional - Depression
	Family/Support Network - Family Stress
	Family/Support Network - Fragile families (divorce, single parents, grandparent)
	Family/Support Network - Foster Care
	Family/Support Network - Addiction/Substance abuse
	Family/Support Network - Military Families
	Societal - Poverty
	Societal - Racism
	Societal - Unemployment
	Societal - Segregation/zoning
	Societal - Human Trafficking

If you have any supporting materials that will help our review process, please send them to us via an attachment(s) in an email.

Click to Email Supporting Documents to the Partner Application Review

If the above link doesn't work with your email client, please email your supporting documents to the email address below using the subject line "Supporting Materials for Breaking Barriers Partner Application"

Breaking Barriers: info@breakingbarriersevent.com

Charities We Help:

African American Youth Harvest Foundation
Toby Keith Foundation
Andy Roddick Foundation
Beyond Batten Disease Foundation
Science Genius
Make A Wish
The REACH Foundation
Sandy Hook Promise