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United Way Chatham-Kent Community Impact Grants 2015

United Way Chatham-Kent

Community Impact Grant

2015Application

Program/Service/Initiative Name:
Name of Applicant/Organization:
Address:
City/Province: Postal Code:
Phone #: Fax #:
Email:
Contact Person:
Phone # (if other than above):
Community Impact Grant Amount Requested:
$
/ Total Cost of Program, Service or Initiative:
$
Sponsoring Organization (if applicant organization is not incorporated and is not a registered charity):
Name of Sponsoring Organization:
Address:
City/Province: Postal Code:
Phone #: Fax:
Email:
Contact Person:
Phone # (if different from above):
Date of Incorporation: / Charitable Registration No.:
BN

Board or Advisory Committee officers and members:

Names: / Occupation/Community Affiliation:

Authorized Signatures:

Board President/Chair / Executive Director/CEO
Date / Date
Description of this initiative:
Is this a new Program? Yes No
If no, please explain
Is this the first time you have applied for a Community Impact Grant for this program?
Yes No If no, when did you last apply: ______
(yyyy/mm/dd)
How long will it take to accomplish this initiative?
If funding is required beyond the period of this initiative, which of the following sources have you investigated for continuous funding?
Federal Government Trillium Foundation
Provincial Government User Fees
Other(please describe)
Please describe the people/population that will benefit by this program, service or initiative:
Estimate the number of people who will benefit by this program, service or initiative:
Please explain how you have determined there is a need:
How has the community shown support for this initiative?
What other community groups are providing the same or similar services?
Have you been in contact with any of these groups to discuss the possibility of a collaborative effort?
Yes No
If yes, please describe the results of this dialogue:
Why are you the most appropriate group or groups to deliver this initiative?
Who will be involved in delivering this initiative and what are their responsibilities?
What additional resources will be required?
What will the initiative accomplish? What difference will you make?
(OUTCOMES) / How will it be accomplished? What tasks, activities, and/or events will be undertaken?
(ACTIVITIES) / What method(s) will you use to measure these accomplishments? How will you know you have achieved your desired outcomes?
(MEASUREMENTS)
Refer to Appendix A and determine what Focus Area and Goalthisprogram, service or initiative addresses, and describe in detail. Although you may feel that it aligns with one or more, please choose the most appropriateFocus Area and Goal.
REVENUE (All Sources) / BUDGET 2015-2016
Federal
Provincial
Municipal
User Fees
Membership Fees
Special Events
Donations (Please specify – e.g. corporate, individual, etc.)
Other: (Please specify – e.g. Trillium Foundation, Community Foundation, etc.)
Community Impact Grant Request

TOTAL REVENUE

EXPENDITURES /
BUDGET 2015-2016
Salaries
Employee Benefits
Building Occupancy
Office Expenses (phone, photocopying,etc.)
Promotion/Publicity
Transportation
Purchased Services
Program materials
Other: (Please be specific)

TOTAL EXPENDITURES

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