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Wisdom Tooth Award

The Delta Dental of Illinois Foundation's Wisdom Tooth Award was created for nonprofit, charitable organizations with programs focused on improving the oral health of children in Illinois.

The $100,000 Wisdom Tooth Award honors and recognizes one outstanding nonprofit organization in Illinois making a significant impact on children’s oral health. The recipient organization has up to two years to use the grant.

Please read the Grant Guidelines and Philosophy section before completing this application. If you have any questions, please contact Lora Vitek, Director of Philanthropy and Community Relations at lvitek@deltadentalil.org.

2017 Wisdom Tooth Award Application

Please complete and submit this form on or before Friday, May 26, 2017 5:00 PM Central Time.
Please note, this application cannot be saved. Tip: Complete your application in Microsoft Word, save the document and copy/paste your answers into each field.

Date
Name of Organization
EIN
Primary Contact
First Name
Last Name
Title
Address
 
City
State
Zip
Email
Phone
Executive Director/President
First Name
Last Name
Email
Request Information

The Delta Dental of Illinois Foundation provides funding for programs and projects that meet one or more of the following objectives.

Please check all that apply:

 
Oral Health Education and Awareness
 
Access to Oral Health Care (select all those that apply)
  Our organization provides preventative oral health care to children
  Our organization provides restorative oral health to children
 
Education for Oral Health Care Professionals

All programs and projects must benefit Illinois children. (For dollar amounts, please enter only numbers, do not enter any symbols.)

Organization Questions
Description of the Organization: (limit 2500 characters)
What is your organization's written mission statement? (limit 1000 characters)
Total organizational budget for the current year?

Please provide amount and source of the organization’s five largest grants other than government or United Way funding for the current year and previous year. (limit 1500 characters)

Please provide names of any organizations currently funding or planning to fund this project. (limit 1500 characters)

What were your fundraising and administrative costs for the last completed year? You can calculate this number by dividing fundraising expenses plus management and general expenses by total expenses. (limit 500 characters)

Please list some of your organization's and/or program's key successes from the last five years. (limit 5000 characters)

What percentage of your Board of Directors supported the organization with a personal financial gift this past year? Does your organization have a Give or Get Policy for your Board of Directors? If not 100%, please explain. Please Provide Details (limit 500 characters)

Program/Project Specific Questions
Program Title: (limit 250 characters)
Please provide a brief description of the program/project for which you are requesting funding. (limit 1000 characters)
How much of the funding for the project will you use in year 1?
How much of the funding for the project will you use in year 2?
What is the total project budget in year 1?
What is the anticipated total project budget in year 2?
For year 1, what percentage of the project would DDIL Foundation fund?
%

What are the biggest impacts Delta Dental of Illinois Foundation funding will have on your program? (For example: "The oral health clinic will be open one additional day each week because of this funding." or "X additional children will receive full treatment plans because of this funding.") (limit 1000 characters)

Is this a new, ongoing or one-time program/project? (limit 500 characters)

Program/Project Start Date
Program/Project End Date

Does your organization serve Illinois exclusively? If no, what percentage of the population served by your organization are Illinois residents? What percentage of the population specifically served by the program/project identified in this grant application are Illinois residents? (limit 1000 characters)

How many Illinois children were served by this program/project during your last completed year? (limit 1000 characters)

How many Illinois children will this grant request specifically serve? What ages? (limit 1000 characters)

What other agencies are you working with on this program/project? (if applicable) Describe partnership or activities. (limit 1000 characters)

What specific oral health need in Illinois does this program/project address? (limit 5000 characters)

What are the specific outcome objectives? Please include specific targets. (limit 5000 characters)

Please include information on how you will measure the impact of this program. (limit 5000 characters)

What are the long-term effects that could result from this program/project? What difference will the $100,000 make to your project and/or organization? (limit 2500 characters)

How do you plan to sustain funding of this program/project? (limit 500 characters)

Please include the following documentation with your grant application. (Click here for instructions.)

Select files to upload (Please combine multiple files into a single zip file.). Combined total size of the uploaded files must be 100 MB or less.

  • The current year's organizational budget. Include projected revenues and expenses. Please categorize expenses under programmatic, management and general, and fundraising.
  • Budget of proposed program\project for which you are requesting funding. (If the requested is for a specific program please provide a very detailed pro forma AND in what specific areas/components Delta Dental of Illinois Foundation's funding will be utilized.)
  • Audited financial statements for the last fiscal year, or if unavailable, copy of Form 990.
  • Latest annual report or a summary of the organization's prior year's activities/outcomes.
  • Current Board of Directors list with related employment affiliations.
  • Copies of evaluation tools (if available)
  • 501(c)3 IRS determination letter
  • Letter of Support (from a partner organization)

File Upload Instructions

Please assemble all of your documents into no more than two zip files that have a combined size of 100 MB or less. Once zipped, click Browse on the application form and select the file. The file will be uploaded with your application.

 

Should you need to submit documents separately, please email them to lvitek@deltadentalil.com by Friday, May 26, 2017 5:00 PM Central Time. Please also note your organization's name in the subject line.

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