Project 3: Grant Agreement and Final Report Form

Project 3: Grant Agreement and Final Report Form

Project 3: Grant Agreement and Final Report Form

Your Name: Phone Number:

Organization: Email Address:

County or Tribe: Date:

Number of people involved in the planning and implementation of this project:

This should include those who helped make presentations to groups, spoke directly with members of your city government, worked on your media campaign, or helped collect Hero Cards or petition signatures.

Number of youth Number of adults

  1. Did you conduct a community assessment? (SHO Handbook, Pages 27-29)

Yes No

  1. Build Stakeholder Support

Planning Team

Tell us who served on the ‘planning team’ for this project. Do not include yourself on this list.

Name / Organization or Sector / What role did they play?

Media Campaign

  1. Attach items related to your media campaign. Include digital audio/video files if available. Include text and name of speaker(s) for any PSAs you used.
  2. What was the value of the coverage of your media campaign? (In other words, if you had to pay advertising for the amount of coverage this project received what would the cost have been?)

$

  1. Address barriers to implementation

Reaching out to stakeholders

Which of the key stakeholders did you involve in order to gain support for this project? (SHO Handbook, Page 16)

Law Enforcement: Yes No / Parents: Yes No
Local Government: Yes No / Youth: Yes No
Judicial System: Yes No

Presentation to community groups

Tell us about the groups that you presented to as part of this project:

Name of Group / Group Type or Sector / # in attendance
  1. Work with City Council in drafting a Social Host Ordinance (SHO)

Was a SHO drafted for your community? Yes No

Was the draft SHO discussed at a City Council related meeting?
(This includes regular council meetings, sub-committee meetings or council retreats.)

Yes No

Describe how the SHO concept advanced in your community via this project. (maximum one page)

What work or activities does your team plan to do regarding SHOs after May 31? (maximum one page)

Signature from organization that the project was implemented and completed.

Vendor's Certificate: I hereby certify under penalty of perjury that the items and totals listed herein are proper charges for materials, merchandise or services furnished and/or services rendered have been provided without discriminations because of age, sex, marital status, race creed, color, national origin, religion, or Vietnam era or disabled veterans status.
Signature

To receive your award of $1,000 for this project:

  1. Scan the following and send as email attachments.

100 signed Hero Cards or an SHO petition with at least 100 signatures;

If appropriate:

Digital photos from meetings of the team working on the Social Host Ordinance (SHO) and pictures of SHO meetings placed on Facebook page;

If appropriate:

Digital photos from City Council meetings where they are considering the Social Host Ordinance (SHO) and pictures of SHO meetings placed on Facebook page;

Final report form, with signature under ‘Vendor’s Certificate’.

  1. Scan and return your required materials (identified above) to .
  2. When this form is completed and the materials identified above are submitted we will send your $1,000 award for this project.

DBHR signature accepting project as completed

(360) 725-15281 of

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