Alex Trebek Innovation and Challenge Fund

Application Form

PERSONAL INFORMATION
SURNAME: / GIVEN NAME(S):
ADDRESS: / CITY/PROVINCE: / POSTAL CODE:
AREA CODE AND PHONE NUMBER`: / EMAIL ADDRESS:
PLEASE CIRCLE THE CATEGORY THAT BEST DESCRIBES YOU:
  1. I am a professor.

Employee number:
  1. I am a student.
Student number: Faculty and Program
  1. I am a Community Partner.
Name of the organization:
If you circled category1 or category 2 for the last question, please answer the next twoquestions.
CITIZENSHIP:
O Canadian citizen
OPermanentresident
O Other (specify) / DO YOU HAVE A VALID PASSPORT?
O Yes
O No
STUDENTS: DO YOU HAVE AN ACTIVE ACCOUNTON THE COMMUNITY ENGAGEMENT NAVIGATOR?
O YesONo
  1. Please name the project, give its location, andindicate its start date and end date.
  1. Please give background information (context)onthe project by explaining what the community need is and howthe project responds to it.
  1. Please indicate why you think the project or approach is innovative.
  2. Please list the project objectives and key activities. If you are a student, please specify the role you will play in the project.
  1. Please explain how the CommunityPartner or communities will be involved in the project design and planning. Indicate the number ofuOttawa students who will participate in the project.
  1. Please list the expected outcomesfor both the end of the project and the medium-term. Specify the number of individuals who will benefit directly and indirectly from the results of the project. (Thedirect beneficiaryis the person who receivesthe services. There may also be indirect beneficiaries, such as family members who benefit from an increase in revenuewhen the direct beneficiary obtains a better job as a result of the support services he or she has received.)
  1. What indicators will you use to determine whether your project is successful and has reached the set objectives?
  1. Please explain how the benefits will continue after the project is over (partnerships with other organizations or stakeholders must be included in the description).
  1. Please indicate how the project results can be scaled up and replicated in other communities.
  1. Please outline the project budget. Note: Funding is not intended to cover the recurring operating costs of the organization, such as salaries. If the organization wishes to include them in the budget, it must demonstrate in its application how it will manage to cover these costs at the end of the project.
  1. Pleaseinclude your letters of recommendation or support (for more information, see application process).

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Revised January 16, 2014