Healing Fund Application Form 1May 2018
Healing Fund
Application Form
The United Church of Canada
3250 Bloor St. West, Suite 200
Toronto, ON M8X 2Y4
*For Office Use Only / File #: Date Received:Project Name:
Note: If writing in application, use black pen, not blue.
Contact Name: / Position:
Organization or Group Name:
Telephone: / E-mail:
Requested Amount ($15,000 max): / Start date: / End date:
*March applications, start after June 1; September applications, start after December 1
Make Cheque Payable to:
Note: Cheques are made payable to organizations and grassroots groups, not individuals.
Contact Address: / Mail Cheque to:
Only If address is different from contact address
Brief Description of Organization or Group(limit description to 200 words)
______
Are you a past Healing Fund recipient? Yes ☐ Healing Fund#______No ☐
Is the organization incorporated? Yes ☐ No ☐
Is the organization a registered charity? Yes ☐ No ☐ Registration #: ______
Is this an Indigenous organization? Yes ☐ No ☐
Which Indigenous group will be served? First Nations ☐ Inuit ☐ Métis☐
Geographical Area: On First Nation☐ Urban area (i.e. city, town)☐ Rural (countryside)☐
How did you find out about the Healing Fund? Word of mouth ☐ United Church website ☐
Newspaper ☐ Pamphlet ☐ Social media ☐Other ☐specify ______
Project Information
Choose one primary focus of your project: Healing ☐ Cultural ☐ Language ☐
Target Group(choose all that apply)
☐Residential School Survivors
☐Intergenerational
☐All of the above / Age Demographic (choose all that apply)
☐Elders/Seniors
☐Adults
☐Young adult
☐Youth
☐Children / Gender Identity (Choose all that apply)
☐Women
☐Male
☐LGBQT2SA+ (Lesbian, Gay, Bisexual, Queer, Trans, Two Spirit, Asexual, other)
Project Description –Provide a description of the project (500 words max).Provide clear details.
What is the project goal (its destination)?
*The project goal or goals will state what the project is going to accomplish or state the desired outcome.
E.x.A group of 20 youth will strengthen their cultural identity at our cultural camp during March Break.
What are the project objectives (the road map)?
Objectives are your action plan, which are specific steps or activities taken to reach the goal(s).
Ex.1. Youth will hear the Creation story and identify how it is connected to their life today
Ex. 2. Youth will go fasting and receive their spirit names and clans and we will feast them.
Ex. 3. Youth will learn traditional roles according to our community’s culture and context.
Additional Project Questions
How is this project connect toaddressing the impacts of residential schools? (200 words max)
How is the community involved in planning, direction, and follow-up? (100 words max)
How will this project benefit the community? How do you plan to sustain the benefits? (100 words max)
Aftercare
How do you plan to emotionally support the participants during the event or project activities? (100 words max)
Do you have a follow-up plan in place for participants once the project is completed? (100 words max)
Evaluation
What is your evaluation plan? (100 words max)
Example: What did you learn? How will you use what you learned in your life? What did you like most? What did you like least?
Healing Fund Community Enquiry
What does wellness look like in your community? (100 words max)
BUDGET TEMPLATE
Example:
Elder / To provide traditional teachings 3 x per month / $100 per session / $300 / $100 space
$500 staff
$60 medicine / $0 / $300
Item / Description / Cost per item / Total Healing Fund Cost / Gifts In-Kind Amount / Funding from Other Sources / Grand total
Total: / $ / $
Note:The budget must show all sources of income (including in-kind gifts) and all anticipated expenses.
The Healing Fund does not cover administrative or capital costs such as purchasing property, furniture, or equipment.If these items are included in the budget, the Healing Fund Council will subtract from the requested amount.
The Healing Fund does not cover wages, but will cover facilitator’s fees and honoraria. Recommended maximum fees are: Facilitators: $250 per day; Elders $100 per day
Budget Narrative: Explain each budget line (e.g., travel, materials, Elders, facilitators) to help the Healing Fund Council understand the reason for the expense indicated.
Letters of Support
Name of Supporter:
Telephone or e-mail:
☐Check box if the letter is included in the package. / Name of Supporter:
Telephoneor e-mail:
☐Check box if the letter is included in the package.
Note:Both letters of support will be from members of the community in which the project takes place.Letters from individuals in the community should be handwritten. Letter are not to be form letters. Letters of support must be received by the deadline date or the application will not be reviewed.
Signature
This application is submitted for consideration by the Healing Fund Council on behalf of the organization noted herein, and the person signing below is duly authorized by the organization to commit to this project on its behalf.
______
Print Name of Primary ContactSignature of Primary Contact
______
Date
If you have any questions, contact the Healing Programs Coordinator at or 1-800-268-3781 / 416-231-5931ext. 4485 or Programs Assistant at ext. 4057.
Send Application to:The Healing Fund,The United Church of Canada, 3250 Bloor St. West, Suite 200, Toronto, ON M8X 2Y4
Deadlines for submission: March 15 and September 15
The use, retention, and disclosure of personal information collected from this form is done in compliance with privacy legislation and adheres to the principles of the Personal Information Protection and Electronic Documents Act (S.C.2000, c.5).