SHIP 3 Mini-Grant Applications Letter of Intent (Non-Binding)

This letter of intent is a non-binding agreement between organizations interested receiving a SHIP mini-grant (cooperative agreement) and Faribault, Martin & Watonwan Counties SHIP Project. This letter of intent will become part of your overall grant application, but does not guarantee your site will receive funding. Additionally, information collected in the letter of intent will be used in the following ways: 1. To aid in development of the FMW SHIP 3 Grant Application, due August 30, 2013 to the Minnesota Department of Health; and 2. To develop a map of potential SHIP sites a requirement of the SHIP 3 Grant Application submitted by Public Health to the Minnesota Department of Health. Upon completing the SHIP letter of intent, organizations will receive: 1. Information about applying for a SHIP mini-grant and/or as a SHIP site. Full application information will be provided to sites completing the letter of intent during the week of August 12, 2013. SHIP mini-grants are competitive and will require sites to develop a work plan and budget. 2. An assigned SHIP contact person who can answer questions related to allowable uses of SHIP funding while you develop your mini-grant proposal.

Instructions PLEASE COMPLETE THIS FORM ON A COMPUTER (DO NOT HAND WRITE FORM)
1. Complete all boxes under section 1: Organization Information. Identify the county(ies) impacted by the proposed work by checking the

corresponding box. List each site/building that will be impacted by your SHIP work separately and provide each sites address and demographic information. Determine one point of contact per organization interested in a SHIP mini-grant. One intent form PER organization is allowed. Please include all the sites wishing to work with SHIP on one form. 2. Identify the strategy(ies) your organization would like to work on. More
detailed information on each strategy can be found by accessing the Strategy Implementation Guides at: http://www.health.state.mn.us/healthreform/ship/2013rfp/ Check the

corresponding box to each strategy your organization plans to apply to work on. Within each of the strategies- select the sub-strategies your sites plans to address. If you have an idea that is innovative or considering a promising practice, please describe your innovative idea in the next text box. Innovative ideas must be related to the strategy area and must involve implementing a policy, systems or environmental change. 3. In addition to the letter of intent, organizations must also submit a letter of commitment. The letter must be printed on your organizations letterhead, should detail past work with SHIP and/or health improvement and should confirm your organizations willingness to partner with FMW SHIP to work on the
SHIP goals of: a. Increasing the number of adults who are a healthy weight from 38% to 47% by 2020. b. Increasing healthy eating and active living in youth, specifically an: i. Increasing the prevalence of youth who eat the recommended number of fruits and vegetables daily from 18% to 30% by 2020. ii. Increasing the prevalence of youth meeting moderate physical activity guidelines from 74% of boys and 68% of girls to 92% of boys and 89% of girls by 2020. c. Decreasing young adults (18-24) who smoke from 27.8% to 18.6% by 2020.

4. Complete this form and letter of commitment and send as an attachment in an e-mail to chera.sevcik@fmchs.com with LETTER OF INTENT FROM: (Your Organizations Name) in the subject heading. Letters of intent are due no later than 5:00p.m. on August 9, 2013.

SHIP 3 Letter of Intent (Non-Binding)

1. Organization Information Organization Name: Contact Person Name/Title: E-mail: Phone:

County(ies) impacted: (please check all counties this organization will work in with SHIP

Faribault Martin Watonwan

Site Name

Site Address

Anticipated Number of People Reached

Target Populations Reached

(please list site name and address if multiple sites, please list all sites and addresses i.e.multiple school buildings, multiple work sites, multiple clinics, etc.)

(i.e.- # of students, # of staff, # of community members, # patients in service area, etc.):

(i.e. % of youth, % of low-income (free & reduced lunch), % uninsured, % Latino, % population over 65, etc.):

2. We plan to apply for a mini-grant with SHIP in the following area(s): More detailed information on each strategy can be found by accessing the Strategy Implementation Guides at: http://www.health.state.mn.us/healthreform/ship/2013rfp/

Strategy Area Community Nutrition

Sub-Strategy Corner Stores Menu Labeling Farmers Markets

Innovative Ideas Innovative Idea:

Community Gardens Farm to Fork Innovative Idea (Explain in next box) Active Transportation Complete Streets/Pedestrian Walkability & Bikeability Joint Use Agreements between recreational facilities and communities. Innovative Idea (Explain in next box) Healthy Schools Active Classroom Physical Education Recess Before/After School Safe Routes to School School Garden Farm to School Concessions/Vending A la Carte Snacks Classroom Incentives Classroom Birthdays and Celebrations School as a worksite Innovative Idea (Explain in next box) Childcare Healthy Eating (LANA) Physical Activity (IMIL) Breastfeeding Support Innovative Idea (Explain in next box) Innovative Idea Innovative Idea: Innovative Idea:

Worksites

Healthy Eating Physical Activity Breastfeeding Support Tobacco Cessation Innovative Idea (Explain in next box)

Innovative Idea:

Health Care

Community Clinical Linkages Advance Community Linkages with State and Federal Health Reform Initiatives Innovative Idea

Innovative Idea:

Smoke-Free Multi-Unit Housing

Innovative Idea

Innovative Idea: