Global Grant Proposal Form for Project G-1172

Section A: Host and International Sponsor Information

1. Host Partner Information

2. International Partner Information

Section B: Community Needs

1. Describe the benefiting community including its location, using any relevant geographic and demographic information (Please be as specific as possible). If the activity is a scholarship, enter "N/A".

2. What community needs have been identified? If the activity is a scholarship, enter "N/A".

3. How are these needs currently being addressed with local resources and/or government agencies, NGOs, etc.? If the activity is a scholarship, enter "N/A".

Section C: Activity Description

1. Summarize the proposed activity(ies) in 250 words or less, including the need it will address, the intended beneficiary(ies), and the potential benefits to the community.

2. Please list any cooperating organization(s) or university(ies) involved in the proposed activity(ies).

3. Describe how the benefiting community will be involved in the activity(ies) (Provide specific examples). If the activity is a scholarship, enter "N/A".

4. Has the benefiting community(ies) confirmed that it would like the activity(ies) to take place?

5. Proposed Start Date: --

6. Proposed Completion Date: --

Section D: Area of Focus

1. With which area(s) of focus is the proposed activity aligned?

[  ]	Peacebuilding and conflict prevention
[  ]	Disease prevention and treatment
[  ]	Water, sanitation and hygiene
[X]	Maternal and child health
[  ]	Basic education and literacy
[  ]	Community economic development

2. Please describe how the activity(ies) will address the goal(s) of the area(s) or focus.

Section E: Project Outcomes

1. What will be the immediate and long-term outcomes of the activity(ies).

2. Explain how all involved parties will act to ensure the sustainability of the activity(ies) and/or outcomes.

Section F: Budget

Section G: Financing

DDF Amount in US$	$12,000
Rotarian Cash Amount in US$	$12,000
Additional Outside Funding in US$	$0
Requested TRF Match in US$	$18,000
Total Financing in US$	$42,000