1-Year Healthy Community Grant
Program Expression of Interest /

Please complete theExpression of Interest for the 1-year Healthy Community Grant and submit to your Regional Healthy Athletes Manager by 11 December 2015. Once completed and signed by theRegional Healthy Athletes Manager, the Expression of Interest will be sent to Special Olympics, Inc. (SOI) for approval. After review by SOI, Programs selected as finalists will be sent an invitation in December 2015 to submit a full proposal.SOI reserves the right to reject any and/or all applications. Of note, this Expression of Interest includes the Healthy Communities Registration Form questions.

PROGRAM INFORMATION
Program Name:
Program Contact Name:
Address:
E-mail:
Phone:
Program Board Chair
Executive or National Director
  1. Information from our athletes and their involvement are critical to creating solutions to the problems they face on a daily basis. Therefore, Programs are required to involve athletes as much as possible in the planning and implementation of their project. Please describe how you would involve an athlete or athletes in the planning and implementation of this grant.

Criteria 4 and 5 (please select one or both): / Brief description of what you are planning to do (150 words maximum)
  • Partnerships for Follow Up Care,
  • Health and Wellness Opportunities, partnerships and/or programming

Note: Funding available is up to $20,000 USD for one year. The final awarded amount will be based onthe local costs and the activities outlined in the application.

  1. Questions: It is valuable for Special Olympics International to learn about your plans to use the 1-year Healthy Community Grant to achieve Healthy Community recognition so that we can connect you to the right resources and help you track your progress. Please answer the questions below.

Geographic Region: Have you identified a particular area or region within your Program that the Healthy Community will be focused? Please describe this area(s) and the estimated athlete population.Note: A Program can choose a geographic area (i.e. a district, state or region rather than the whole country or state) within their Program to pursue recognition as a Healthy Community rather than their whole Program; in which case the criteria need to be met only for the athletes in that area.

Criteria 2–Special Olympics Healthy Athlete: Please list the Healthy Athletes disciplines your Program currently offers.

Disciplines Offered / Approximate Number of Exams Provided per Year

If applicable, which additional disciplines will you add to achieve Healthy Communities recognition (a minimum of three are required)

Criteria 3 - Local Funds and Support: Please estimate what percentage of your total Healthy Athletes event costs over the last year is funded by local (non-Special Olympics International.) funds including VIK services? VIK services include any service or item that is provided to support the Healthy Athletes event including transport, Special Olympics staff time, volunteer time, clinical space, food, equipment and giveaways.

Criteria 4 - Follow-up Care: Currently, what percentage of athletes receiving a referral after a Healthy Athletes event have a place and know where to go for treatment?Please estimate to the best of your ability for each discipline your Program offers.

Discipline / % of referred athletes with place to go / Method of tracking

Please describe your plans to increase this percentage for at least two disciplines as per the Healthy Community criteria.

Criteria 5 - Health and Wellness Programming outside of Healthy Athletes: Please estimate what percentage of your athletes, within your area selected for participation in Healthy Communities, are currently engaged in Health and Wellness Programming outside of Healthy Athletes?

Please describe your Program’s plans for recurring health education and/or engagement activities to improve health or prevent illness.

SIGNATURES
I support the above application:
Executive or National Director: / Date:
Board Chair: / Date:
Regional Healthy Athletes Manager: / Date:

Please send completed Expression of Interest forms to the appropriate Regional Healthy Athletes Manager:

  • Special Olympics Africa: Ashley Hoskins,
  • Special Olympics Asia Pacific: Avi Tania,
  • Special Olympics East Asia: Jason Zhan,
  • Special Olympics Europe Eurasia: Bjoern Koehler,
  • Special Olympics Latin America: Gonzalo Larrabure,
  • Special Olympics Middle East/North Africa: Salma El Ghandour,
  • Special Olympics North America: Heather