Community Grant Program

Sample Application
This sample application is based on a successful Community Grant Program
application. It is designed to assist you in the application process by providing
an example of several of the features we are looking for in an application. Please
also refer to our Application Guide for further help.

If you have questions, need additional assistance, or have suggestions for

improving this example, please contact Rhonda Newton, CIF Grants Administrator
at 306.780.9308 or by email at rnewton@[Link]

[Link]
COMMUNITY  GRANT  PROGRAM  
APPLICATION  FORM  

Application  Deadline  (select one)  

       ᴏ    April  1  -­‐  Annual          3
ᴏ    October  1  –  Annual                              ᴏ    February  1  -­‐  Summer  

Type  of  Grant  (select one)  

3    Annual  Local  ($25,000 maximum)
       ᴏ ᴏ    Summer  Local  ($5,000 maximum)  
       ᴏ    Annual  Provincial  ($50,000 maximum)                ᴏ    Summer  Provincial  ($10,000 maximum)  

Region  Where  Project  Will  Be  Delivered  (select one)  

To  determine  the  correct  region  refer  to  the  map  at  [Link]/grants/apply-­‐here.  
                   ᴏ    North          ᴏ    Provincial  (select one below)  
3    Central  
                   ᴏ  ᴏ    The  project  will  occur  in  more  than  one  region.  
                   ᴏ    South         ᴏ    Project  participants  will  come  from  more  than  one  
region.  
This num
ber needs
Grant  Request  $  14,500 to match th
ea
you reques mount
t in the
budget, la
ter in the
application
APPLICANT  INFORMATION   .
(Please provide your responses in the shaded areas).  

Organization   Anytown Centre for Inclusion and Learning

Address   Box 123

Community   Anytown, Saskatchewan Postal  Code    S0K 1Z0

Primary  Contact  Person   Alternate  Contact  Person  

Ms. Jane Smith John Doe
Position  /  Job  Title   Position  /  Job  Title  
Executive Director Program Coordinator
Phone   Phone  
(306) 123-4567 (306) 123-1234
Email   Email  
janesmith@[Link] johndoe@[Link]
Fax   Fax  
(306) 123-7654 (306) 123-7654

Community Initiatives Fund 1 Jan 2017

 ELIGIBILITY  REQUIREMENTS  
ELIGIBILITY  REQUIREMENTS  
Nonprofit  organizations  incorporated  in  Saskatchewan  are  eligible  for  Community  Initiatives  
Nonprofit  organizations  incorporated  in  Saskatchewan  are  eligible  for  Community  Initiatives  
Fund  grants.    If  the  applicant  is  an  unincorporated  community  group,  an  eligible  organization  
Fund  grants.    If  the  applicant  is  an  ELIGIBILITY  
unincorporated   REQUIREMENTS   community  group,  an  eligible  organization  
must  accept  the  funds  on  their  behalf.  (Refer� to� �rogra�� �ui�elines� or� [Link]/grants/eligibility�
must  accept  
Nonprofit   the  funds  oin  
organizations   their  behalf.  in  (Refer�
ncorporated   Saskatchewan  
to� �rogra�� ��i�elines� are  eligible   for  Community  Initiatives  
or� [Link]/grants/eligibility�
for� furt�er� infor�ation).  
Fund   grants.  
for� f�rt�er�  If  the  ).  
infor�ation applicant  is  an  unincorporated  community  group,  an  eligible  organization  
Is  the  organization  incorporated?  
must  accept  the  funds  on  their  bIs  ehalf.  
the  o(rganization  
Refer� to� �rogra�� incorporated?  
��i�elines� or� [Link]/grants/eligibility�
ᴏ    Yes   ᴏ    No  
for� f�rt�er� infor�ation).   3
ᴏ    Yes  
Provide  the  Saskatchewan  incorporation    
ᴏ    No  
Provide  the  Saskatchewan  incorporation   Is  the  organization   Provide incorporated?   the name of the organization that will
number.   administer funds on behalf
number.   ᴏ    Yes   ᴏ    Nof
o   the applicant.
1 0 1 4 5 6 7 8 9
Provide  the  Saskatchewan  incorporation  
number.   Indicate the relationship between thetapplicant
Indicate   the   relationship   between   he  
and Indicate   this the  relationship  between  the  
organization.
applicant  and  this  organization.  
This is th applicant  
ᴏᴏ   Administering and  tFunds
his  organization.  
Only
e incorpora  Administering   Funds   Only  
number fr
om ISC, n
tion ᴏ Indicate  
ᴏ   Parent   A t he  
dministering  
Organizationr elationship  
F unds  
AssociatedObnly  
etween   the  
With
charity n
umber fro
ot the ᴏ  
applicant     P
Committee/Group arent   O
a rganization  
nd   t his   o A ssociated  
rganization.   With  
you don’t m CRA. If ᴏ    Parent  Organization  Associated  With  
ᴏ  ᴏ  
         ACdministering  
ommittee/Group  
   Program DeliveryFPartner unds  Only  
ha
need an el ve one, you will      Committee/Group  
to act as en
igible org
anization ᴏᴏ  Other  Program  Delivery  Partner  
d ᴏ  
ᴏ      PParent   Organization  
rogram   Delivery  Partner   Associated  With  
and accep orsing partner ᴏ  
The   O ther  
Endorsing Partner has agreed to:
t the fund  ᴏ  
         COommittee/Group  
behalf. s on your ther  
ᴏA  Accept and distribute project of  funds according
The maxim ᴏ  c  Pompleted   “Declaration  
rogram  Delivery   Partner   Endorsement  
um length tocthe
A   project “as
ompleted   approved by
Declaration   of  the Community
Endorsement  
project is
12 month of a Form”  
ᴏ  Initiatives   O must  
ther   Fund
be  submitted  with  the  
s Form”  must  be  submitted  with  the  
ᴏapplication.  
A  Acknowledges
completed  “Declaration  
application.   and accepts othe responsibility
f  Endorsement  
Form”  must  be  submitted  with  and
for ensuring that all obligations the  conditions
relating to the grant are met
application.  
PROJECT  INFORMATION  
PROJECT  INFORMATION
PROJECT INFORMATION  
Community   Initiatives  
PROJECT   Fund  Funding  Objectives  
INFORMATION  
Indicate  the  CIF  objectives   Community  
that  your  pInitiatives  
roject  will  Faund   Funding  
ddress.   Objectives  
�elect� only� one� �ri�ary� ob�ecti�e� an�� u�� to�
Indicate  
t�ree� ot�er�the   CIF  objectives  
���itional� ob�ecti�es.t  hat  your  project  will  address.  �elect� only� one� �ri�ary� ob�ecti�e� an�� ��� to�
Additional  Community  
t�ree� ot�er� ���itional� ob�ecti�es.
Primary    
Funding   Initiatives  Fund  Funding  Objectives  
Objectives  
Primary  
ᴏ   the  CAdditional  
Indicate   IF  objectives  
ᴏ   Funding  
that  your  
Healthy   gO bjectives  
p roject  
rowth   will  
and   address.  �elect�
development   of  only� one� �ri�ary�
children   ob�ecti�e� an�� ��� to�
and  youth  
t�ree� ᴏ  
ot�er� ���itional�ᴏ  ob�ecti�es.  
Healthy   g rowth   a nd   d evelopment  
3 Individual,  family  and  community  wellbeing   o f   c hildren   a nd   y outh  
ᴏ   ᴏ  
Primary  
3ᴏ   Additional  
ᴏ   Funding  
Individual,   Objectives  
faamily   and  community   wellbeing  
ᴏ   ᴏ   Supportive   nd  inclusive   communities  
ᴏ   ᴏ  
ᴏ  
3 Healthy   g rowth  
Supportive  aend   a nd   d evelopment  
inclusive  acommunities   o f  children  and  youth  
ᴏ   ᴏ   Community   ngagement   nd  capacity  building  
ᴏ   ᴏ  
ᴏ   Individual,  
Community   family   and  community  
engagement   wellbeing  
and  capacity   building  
ᴏ   ᴏ   Supportive  and  inclusive  communities  
Funding  Priorities  
ᴏ   ᴏ   Community  eFunding  Priori8es  
ngagement   and  capacity  building  
From  the  list  below  indicate  the  priority  Funding   Priorities  
areas  that   your  project  will  address.  �elect� all� t�at� a��ly.�
From  the  list  below  indicate  the  priority  areas  that  your  project  will  address.  
From  the  
�ealt�y� list  an��
growt�� below   indicate  of�
�e�elo��ent� the   priority  
c�il�ren� an��ayout��
reas  that   your  p�roject  
�n�i�i�ual�� a�ily�� w ddress.  � �Select  all  that  apply.  
ill  � ao��unity�
n�� elect�
ellbeing� all� t�at� a��ly.�
�ealt�y�
o   growt�� an�� �e�elo��ent�
Early  childhood  development   of�
Healthy  growth  and  development  of  children  and  youthc�il�ren� Funding  
an�� yo�t�� P riorities  
�n�i�i��al�� � a�ily� � n�� � o���nity�
o   Increasing  physical  activity  levels    
Individual,  family  and  community  wellbeing � ellbeing�
From  
o   the  scchool/weekend  
o   After  
Early   list  below  
hildhood   indicate  
development   the  priority  areas  that  
program   o  your  
o   project  
Increasing  
Family   pw
support   ill   address.  
hysical   activity  l�evels  
programming   elect�  all� t�at� a��ly.�
o  
o   Early  childhood  development  
o  
�ealt�y� After  
Summer   growt�� school/weekend   program  
an�� �e�elo��ent�
camp/recreation   of� c�il�ren� an�� yo�t��
program   3o   Increasing  physical  acIvity  levels    
o  
�n�i�i��al��
o   Family  
Problem   � a�ily� support  
� n��p� rogramming  
gambling  o���nity�
awareness,   � ellbeing�
education  and  
3
o  
o   AUer  school/weekend  program  
o   Summer  
Community-­‐school  
Early  childhood  development   c amp/recreation   program  
partnership   o  
o   Problem  
Family  support  programming  
                 prevention  
o   Increasing   g ambling   aactivity  
wareness,  
program  
physical   education  
levels     and  
3
o   Summer  camp/recreaIon  program  
o  
o   Community-­‐school  
Youth  
After   sechool/weekend   partnership  
ngagement/volunteerism/leadership  
program                  
o   Problem  gambling  awareness,  educaIon  and  
o   Addictions  
Family     p revention   p rogram  
awareness,  
support   education  and  prevention  
programming  
o  
o   Youth  
o   Community-­‐school  partnership  
 Summer   e ngagement/volunteerism/leadership  
                   development  
camp/recreation  program   o                    prevenIon  program  
o    Addictions  
                 program  
Problem   awareness,  
gambling   education  
awareness,   education  and  prevention  
and  
3                      dpevelopment  
o   Youth  engagement/volunteerism/leadership    
o  
o  
Youth  
Community-­‐school   rogramming  partnership                    
o   AddicIons  awareness,  educaIon  and  prevenIon  
o   Violence    
                 prevention   p rogram  
and  bullying   awareness,  education  and  
program  
Youth  epngagement/volunteerism/leadership  
o                        development  
Youth   rogramming   o   Addictions  
o   Violence  and   bullying  aewareness,  
awareness,   ducation  aend   ducation   and  
prevention  
                   program  
                     d�nitiati�es�
o Youth  programming  
�o��unity� evelopment  
�un��                    program  
��o   Violence  and  bullying  awareness,  educaIon  and   July  2015
o   Youth  
�o���nity� �nitiati�es� p rogramming  
��n�� o   Violence  and  bullying  awareness,  education  
��                    prevenIon  program   Janand  
2017
o   Program  that  promotes  and  encourages  adopIon  
�o���nity� �nitiati�es� ��n�� ��                    of  healthy  life  styles   Jan 2017
o   Reducing  barriers  to  enable  access  and  
                   parIcipaIon
 Youth  engagement/volunteerism/leadership     o   AddicIons  awareness,  educaIon  and  prevenIon  
                     development                      program  
o Youth  programming   o   Violence  and  bullying  awareness,  educaIon  and  
                   prevenIon  program  
3
o   Program  that  promotes  and  encourages  adopIon  
                   prevention  program  
                   prevention  
o                      of  healthy  life  styles  
Program   program  
that  promotes   and  encourages  adoption  
o   Program  
            3
     
o   Reducing  barriers  to  enable  access  and     o f  
                   of  healthy  
h t hat  
ealthy  p romotes  
l ife  
life  
s and  encourages  adoption  
tyles  
o                      parIcipaIon
Reducing   barriers   to  setyles  
nable  access  and  
o    Reducing  
                 participation   barriers  to  enable  access  and  
Suppor6ve  and  inclusive  communi6es
Supportive and inclusive communities Community  engagement  and  capacity  building
             
Community engagement and capacity building       p articipation  
Supportive and inclusive communities Community engagement and capacity building
o   Community  
o   Community  centennial  
o   Organization  
Community  centennial  
centennial  
anniversary  
o   Initiative  
o  
o   Initiative  
3
IniIaIve  that  encourages  volunteerism,  
that  encourages  
t hat   e ncourages  
             community  participation  and  leadership  
volunteerism,  
v olunteerism,  
o   OrganizaIon  anniversary  
Organization   anniversary                community  parIcipaIon  and  leadership  
             community   participation   and  leadership  
o   Other   community,   organization  or  historical   o   Training   and  support   for  individuals   to  become  
o  
o   Other  community,  organizaIon  or  historical  
 Other   community,  
             milestone   organization  or  historical  
event   o    Training  
3
o   Training  and  support  for  individuals  to  become  
           community   and  support  
leaders   for  individuals  to  become  
o                  milestone  event  
               milestone  
Program   event  
or  event   specific  to  Aboriginal  culture,   o                community  leaders  
             community  
Training   for  staff  leaders  
and/or  volunteers  of  nonprofit  
o   Program  or  event  specific  to  Aboriginal  culture,  
o    Program   or  event  
             identity,   specific  to  Aboriginal  culture,  
teachings   o  
o   Training  for  staff  and/or  volunteers  of  nonprofit  
 Training  
           organizations   for  staff  and/or  volunteers  of  nonprofit  
o                  idenIty,  teachings  
               identity,  
Festival   or  event   showcasing  Saskatchewan  artists,   o                organizaIons  
teachings                organizations  
Initiative   that  supports  increased  collaboration  
o   FesIval  or  event  showcasing  Saskatchewan  arIsts,  
o    Festival   or  event  
           artisans,   performers   3
showcasing  Saskatchewan  artists,   oo   IniIaIve  that  supports  increased  collaboraIon  
 Initiative  
           between   that  nsonprofits  
upports  increased  
and  others  collaboration  
             artisans,  
o                arIsans,  performers  
Festival   performers  
or  event   celebrating  diversity,  cultural  or                between  nonprofits  and  others  
             between  nonprofits  and  others  
o   FesIval  or  event  celebraIng  diversity,  cultural  or  
o  Festival   or  event  celebrating  
           intergenerational   diversity,  cultural  or  
understanding,   Projects that are ongoing,
               intergeneraIonal  understanding,  
           intergenerational  understanding,   like this one, still need
to indica te a start and
end date. The start
date must be at least
Project  Title   Inclusive Social Club two months after the
Project  Title   application deadline you
Project  Title
Project  Start  Date   2016/12/01 Project  End  Date   are applying to.
2017/11/30
Project  Start  Date   Project  End  Date  
Location(s)  of  Project  Activities  (communities, Various
Project  Start  Date Project  End  Date locations within Anytown such as the recreation
Location(s)  
facilities)   o f   P roject   A ctivities   ( communities, centre, church hall, shopping mall, and sporting venues.
facilities)  
Loca8on(s)  of  Project  Ac8vi8es  (communi6es,  
Executive  Summary  of  Project  (maximum 500 words)  Provide  a  brief  summary  of  the  project  that  
facili6es)
Executive   Summary   of  Project  
may   be  used   as  a  project   description   (maximum for  o500 ur  wordsgrant  )  aPdjudication  
rovide  a  brief   and   summary  
communication   of  the  project   that  
purposes.  
may  be  used  as  a  project  description  for  our  grant  adjudication  and  communication  purposes.  
The Anytown Centre for Inclusion and Learning works to reduce barriers facing young
Execu8ve  Summary  of  Project  
adults with complex physical (maximum  500  words disabilities. We create )  Provide  a  brief  summary  of  the  project  that  
opportunities through our Inclusive
may  be  used  as  a  project  descripIon  for  our  grant  adjudicaIon  and  communicaIon  purposes.
Social Club, the Teaching and Learning Centre, the Summer Literacy Program, and Path
to Future Endeavours.
The Inclusive Social Club is led by five vibrant young adults with and without
disabilities that plan and carry out monthly social, recreational, and physically
active events for young adults with complex physical disabilities, volunteers, and the
entire community. Our staff work with, and mentor, the planning team to increase
their leadership skills and to develop program planning skills (assessing, planning,
promoting, implementing, and evaluating). The team actively recruits and orientates
Community  Ini6a6ves  Fund                                                                                                                  8
volunteer university students to assist with event 4                                                                                                                                                August  2014  
implementation.
Two events are offered, the largest event is an adapted hip-hop initiative held monthly.
The second event changes monthly, is typically scheduled on weekends or in the
evenings, and can include a variety of activities such as barbeques, sports events,
bowling, and holiday celebrations.

Community Initiatives Fund 3 Jan  2017

Community Initiatives Fund 3 Jan  2017
Project  Objectives    Briefly  describe  the  community  and  the  issue  your  project  is  designed  to  
address.  If  the  project  has  been  offered  before,  briefly  describe  the  results  and  any  changes  
that  have  been  made  to  the  project  to  improve  outcomes  for  participants.    
Project  Objectives    Briefly  describe  the  community  and  the  issue  your  project  is  designed  to  
Project  OIbjectives  
address.    Briefly  
f  the  project   has  bdeen  
escribe   the  cbommunity  
offered   and  dtescribe  
efore,  briefly   he  issue   your  
the   project  
results   and  is  adny  
esigned   to  
changes  
address.   I f   t he   p roject   h as   b een   o ffered   b efore,   b riefly   d escribe  
that  have  been  made  to  the  project  to  improve  outcomes  for  participants.     t he   r esults   a nd   a ny   c hanges  
that  have  been  made  to  the  project  to  improve  outcomes  for  participants.    
The Inclusive Social Club aims to address three issues. First is to reduce the multitude
of barriers that young adults with disabilities encounter to participate in community
social activities. Through program education and participation, barriers such as lack
of knowledge and social ineffectiveness will be reduced. By providing events that are
truly accessible and free of charge, environmental barriers can also be decreased. Project
Project  Objectives    Briefly  describe  the  community  and  the  issue  your  project  is  designed  Nto   that the
Second is the lack of opportunities for adults with complex disabilities to actively otijeccetives talks abouant d
address.  If  the  project  has  been  offered  before,  briefly  describe  the  results  and  any  changes   Ob es,
engage in leadership opportunities, gain employment skills, and to participate in issues, challenomg es for
that  have  been  made  to  the  project  to  improve  outcomes  for  participants.     outc
the community in a meaningful way. Through working with and mentoring the expectecipd ants, not the
pa r ti
five member team, we plan to support young adults in gaining experience and activitie
s
developing leadership skills.
Finally, the social club is an opportunity for all young adults in the community to
develop skills, participate in community activities and work alongside their peers.

Describe  who  will  participate  in  and/or  benefit  from  the  project.  
If the project has been offered before, briefly describe the results and any changes that have
been made to the project to improve outcomes for participants.

The Inclusive
Describe   who  w Social Club hasin  
ill  participate   been ongoing
and/or   forfthree
benefit   rom  tyears. Each year our members complete
he  project.  
Describe   w ho   w ill   participate   in   and/or   b enefit   f rom  
surveys and we continue to see them become more engaged and less isolated which leads to t he   p roject.  
healthier lives. The number of new and returning members has increased each year. In the
past two years we have went from 20 members to 45, and we are projecting over 50 in the
coming year. As well, many volunteers have reported that the experience has improved their
skills and added to their education. The only change this year is the addition of a hip-hop
dance class once a month, which is based on the feedback received from our members.

Describe  
Select   the  waho  
ge  w ill  the  
of   participate   in  w
audiences   and/or  
ho  will  bbenefit  
enefit  from  
from  the   project.  
your   project.  Select  all  that  apply.  
ᴏ      Children  0  –  5  years   ᴏ      Children  6  –  11  years  
Young adults
ᴏ      Teens  12  –  16  years   with and without a disability inᴏ    our  Youth   community
17  –  25  years   benefit from the
program.
ᴏ      Adults   Those with disabilities have the opportunity ᴏ      Older  to be active
adults   (55+  and years)   included while
Select  the  age  of  the  audiences  who  will  benefit  from  your  project.  Select  all  that  apply.  
participating
Identify   the   in community events, socializing with current friends, meeting new
Select  
ᴏ      Children   the   0d  emographics  
age   –o  5f    ythe   of  the  
audiences  
ears   wpho  
articipants  
will   and/or  
benefit   from  
ᴏ      Children   byeneficiaries  
our    –  11  y.  ears  
p6roject.   SSelect  
elect  aall  ll  
tthat  
hat  aapply  
pply..  
friends,
ᴏ  
ᴏ              FTCemale   and increasing their recreational and physical
ᴏ  
ᴏ              YPCouth   activity
re-­‐school   knowledge and
ᴏ   hildren  
eens   12  0–    –1  6  
5  yyears  
ears   ᴏ   17  6–    –S2  tudents  
hildren   11  
5   years  
years  
skills.
ᴏ      
ᴏ          A
ᴏ   M Teens  Their
ale   diverse
dults  12  –  16  years   abilities are valued and they ᴏ      
ᴏ          O
ᴏ   E have the
lementary  
Youth   opportunity
lder  a1dults  
7  –  25   S tudents  
years  
(55+   years)  to contribute.
ᴏ  
Those
ᴏ          FAirst   Nations  disabilities that participate haveᴏ  
without
dults          JOunior/High  
ᴏ  the adults  S(chool  
opportunity
lder   Students  
to.  Sform
55+   yelect  
ears)   meaningful
Identify   the  demographics  of  the  participants  and/or   beneficiaries   all   that  apply.  
ᴏ      Metis  the  demographics  
relationships,
Identify   and gain volunteer experienceaand
of  the  participants   ᴏ      Pskills.
nd/or   ost-­‐secondary  
beneficiaries   S.  tudents  
Select  all  that  apply.  
ᴏ      Female   ᴏ      Pre-­‐school   Students  
ᴏ  
ᴏ              N ewcomers  to  Canada  
Female   ᴏ  
ᴏ              C ommunity  
re-­‐school  SSVtudents   olunteers  
ᴏ   M ale   ᴏ   EPlementary   tudents  
ᴏ  
ᴏ              U rban   Residents   ᴏ  
ᴏ              N onprofit  Board   Members/Volunteers  
ᴏ   FMirst  
ale  Nations   ᴏ   JEunior/High  
lementary   SSchool  
tudents   Students  
ᴏ      
ᴏ          M R ural  
First   R esidents  
Nations   ᴏ  
ᴏ       N onprofit   S taff  
ᴏ  
Select   etis  
the   age  of  the  audiences  who  will  benefit  ᴏ          PJunior/High  
from   ost-­‐secondary  
your  project.   School   Students  
SStudents  
elect   all  that  apply.  
ᴏ       M etis   ᴏ  
ᴏ          O P ther  _____________________________  
ost-­‐secondary   S tudents  
ᴏ      N ewcomers  
Children   0  –  t5o    yCears  
anada   ᴏ      Community   hildren  6  –  V1olunteers  1  years  
ᴏ          U
ᴏ  
Community  
N ewcomers  
rban   R esidents  
Teens  12  –  16  years  
I nitiatives  
t o   C
F
anada  
und  
3 Youth  17  –  25  years  
ᴏ  
ᴏ  
4  
 
   
  N C ommunity  
onprofit   B V
oard  olunteers  
Members/Volunteers  
Jan  2017
3        RAUural  
ᴏ   rban  RResidents  
dults   esidents   ᴏ          N Oonprofit  
lder  adults  SBtaff  oard  
(55+  M embers/Volunteers  
years)  
ᴏ      Rural  tRhe  
Identify   esidents  
demographics  of  the  participants  and/or   ᴏ      O Nther  
onprofit  
beneficiaries   Staff   .  Select  all  that  apply.  
_____________________________  
ᴏ      Female   ᴏ          POre-­‐school  
ᴏ   ther  _____________________________  
Students  
Community  
ᴏ      Male   I nitiatives   F und   4  
ᴏ      Elementary  Students   Jan  2017
Community   I nitiatives   F und   4   Jan  2017
ᴏ      First  Nations   ᴏ      Junior/High  School  Students  
ᴏ      Metis   ᴏ      Post-­‐secondary  Students  
ᴏ      Newcomers  to  Canada   ᴏ      Community  Volunteers  
ᴏ      Urban  Residents   ᴏ      Nonprofit  Board  Members/Volunteers  
 ᴏ Children  0  –  5  years   ᴏ Children  6  –  11  years  
ᴏ Teens  12  –  16  years   ᴏ Youth  17  –  25  years  
ᴏ Adults ᴏ Older  adults  (55+  years)
Iden8fy  the  demographics  of  the  par8cipants  and/or  beneficiaries.  Select  all  that  apply.
Where  will  participants  and/or  beneficiaries  come  from?    Select  all  that  apply.  
ᴏ3
ᴏ      Female   School(s)   ᴏᴏ      Pre-­‐school  Students  
Region  
ᴏ3 Male  
ᴏ       N eighbourhood(s)   ᴏ      
ᴏ Elementary  Students   Province  
ᴏ3
ᴏ      First  NaIons   Town/City   ᴏᴏ      Junior/High  School  Students  
Out-­‐of-­‐Province  
ᴏᴏ      MeIs   Town/City  and  Surrounding  Area   3
ᴏᴏ      Post-­‐secondary  Students  
Other  _____________________________  
Where  
ᴏ Newcomers  to  Canada   w ill   p articipants   a nd/or   b eneficiaries   c ome   f
3 Community  Volunteers  
ᴏ rom?    Select  all  that  apply.  
ᴏ  
ᴏ3
Identify      Urban  Residents  
School(s)   any   oarticipants  
f  the  following   characteristics   that   ᴏᴏ  m    ay   Region   apply   to  the  
Where   w ill   p a nd/or   beneficiaries   c ome   Nonprofit  Board  Members/Volunteers  
frovince  
rom?    Select   all  tphat  articipants  
apply.   and/or  
ᴏ  
ᴏ3  
beneficiaries.     N eighbourhood(s)   ᴏ       P
ᴏ        Rural  Residents  
ᴏ   T chool(s)   Select  all  that  apply.  
 Sown/City   ᴏᴏ    Nonprofit  Staff  
ᴏ    Rut-­‐of-­‐Province  
       fO egion  
ᴏ  ᴏ        L  N
Where   iving   w i
eighbourhood(s)   n  
ill   p overty  
articipants   a nd/or   b eneficiaries   c ome   3
ᴏᴏ  
ᴏ        O M ental  
rom?    SIndividuals
illness  
Other  _____________________________  
 Pther  
rovince   elect   all  that  apply. with   disabilities
ᴏ  
ᴏ  ᴏ            TS  Tchool(s)  
own/City  
ingle   p and  Surrounding  Area  
arents   ᴏ  
ᴏ       R C hronic  
egion   _____________________________  
h ealth   c ondition  
Where   own/City   will  participants  and/or  beneficiaries  come   ᴏ  f    rom?   Out-­‐of-­‐Province  
 Select  all  that  apply.  
ᴏ       NU
ᴏ        S  Tchool(s)   nemployed/underemployed  
eighbourhood(s)  
own/City  and  Surrounding  Area  
Where  will  par8cipants  and/or  beneficiaries  come  from?     ᴏ   O verweight/obese  
ᴏ        R  Orovince  
    P ther  _Select  all  that  apply.
____________________________  
ᴏ  
Identify  
ᴏ      TGown/City   any  of  the  following  
ang-­‐related/justice   system  characteristics  
involved   that  ᴏ   ᴏ  
m    ay   O egion  
apply  to  the  participants  and/or  
Vut-­‐of-­‐Province  
ulnerable/At-­‐risk  
ᴏᴏ      N
beneficiaries.  
   School(s)  
ᴏ  Identify  
eighbourhood(s)  
TPown/City  
hysical   a ny   oaSf  nd  
elect  
disabilities   t
all  that  apply.  Area  
Surrounding  
he   f ollowing   c haracteristics   t hat   ᴏᴏ  
ᴏ  m
   PIsolated  
   Region  
O ay  
rovince  socially/geographically  
ther   _____________________________  
apply   to  the  participants  and/or  
ᴏ  
ᴏ    
   
  T
L C own/City  
iving   i
ognitive/intellectual  n   p overty   d isabilities   ᴏ  
ᴏ    
     O
M O ut-­‐of-­‐Province  
ental  
ther   _ i___________________________  
llness  
ᴏbeneficiaries.   ᴏ Province  
3        Neighbourhood(s)  
ᴏ  
ᴏ   TSLGBTTQA  
own/City  
ingle   pny   aSnd  
arents   elect   all  that  apply.A  rea  
Surrounding   ᴏ  
ᴏ        O ther  
COhronic   ______________________________  
hto  
ealth  
the  cpondition  
Identify  
ᴏᴏ  ᴏ        Town/City   a
 ULnemployed/underemployed  
iving  in  poverty   o f   t he   f ollowing   c haracteristics   t hat   ᴏ        ay  
m
ᴏᴏ   ther  
aental  
pply  
 Out-­‐of-­‐Province  
 OM verweight/obese  
___________________________  
illness   articipants  and/or  
ᴏ    
beneficiaries.     H omeless/Sub-­‐standard  
ᴏ    Town/City  and  Surrounding  Area
 Sang-­‐related/justice  
ingle   Select  all  that  apply.  
parents   h ousing   ᴏ      
ᴏ      ay   O ther   _ ___________________________  
 Other  _____________________________  
 Culnerable/At-­‐risk  
hronic  
ᴏIdentify  
ᴏ   any   of  the  following   characteristics   that  ᴏᴏ   m apply  tho  ealth   the  pcarticipants  
ondition   and/or  
ᴏ  ᴏ            G
L  U iving   i n   p
nemployed/underemployed   overty   system   involved   ᴏ       V
M ental  
ᴏ        I  solated  
Overweight/obese  i llness  
beneficiaries.  
ᴏ   Select  all  that  apply.  
ᴏ  ᴏ            P
S  G hysical  
ingle   p
ang-­‐related/justice  
disabilities  
arents   sdystem   involved  
ᴏ  
ᴏ       C  Vhronic   hsocially/geographically  
ealth  condition  
3
ᴏ      LCiving   in  poverty  
ognitive/intellectual   isabilities   ᴏ  ᴏ        MO ulnerable/At-­‐risk  
ental  
ther   _ illness  
___________________________  
Which   of  the   following  focus  areas  will  be  included  
Iden8fy  any  of  the  following  characteris8cs  that  may  apply  to  the  par8cipants  and/or  
ᴏ      Unemployed/underemployed   ᴏ  ᴏ        O  iIn   the  project?  
verweight/obese   Select  any/all  that  apply.  
ᴏ  ᴏ        SL  PGBTTQA   hysical  
ingle   disabilities  
parents   3
ᴏ      C O solated  
hronic   hsealth  
ocially/geographically  
ther  ____________________________   condition  
ᴏ    
beneficiaries.  
ᴏ        H   GE mployment  
ang-­‐related/justice  
 Comeless/Sub-­‐standard  
ognitive/intellectual   s kills/preparation  
Select  all  that  apply. s ystem   i nvolved  
disabilities   ᴏ        V R educing  
ulnerable/At-­‐risk   d iscrimination/racism  
3
ᴏ   U nemployed/underemployed   housing   ᴏ  ᴏ        O  Overweight/obese  
ther  _____________________________  
ther   ___________________________  
ᴏ  ᴏ        P N utrition/food  
hysical  
 Lang-­‐related/justice  
GBTTQA   d isabilities   s ecurity   ᴏ        I P ersonal  
solated   choices/coping  skills  
socially/geographically  
ᴏ      G system  involved   ᴏ  ᴏ        V  Oulnerable/At-­‐risk  
ther  ____________________________  
3    PA  Hhysical  
ᴏ  ᴏ        C
ᴏ  
ᴏ      LAGBTTQA  
cademic  
ognitive/intellectual  
omeless/Sub-­‐standard   achievement/support  
disabilities  
rts  and  culture,  theatre,  music  
disabilities  
housing  
Community  Ini6a6ves  Fund                                                                                                                  8
ᴏ  ᴏ          O
3          IOHP  solated  
ᴏ  
5
ousing  
Other   supports  
ther  _____________________________  
___________________________  
socially/geographically  
ᴏ                                                                                                                                                  August  2014  
ublic  
ther  _a___________________________  
wareness/education  
3    CSport  
ᴏ  
Which  
ᴏ      H
ognitive/intellectual  
of  atnd  
omeless/Sub-­‐standard  he  rfecreation  
ollowing  focus   disabilities  
areas  will  be  included  
housing  
ᴏ      O
ᴏ        O
ther  
Rin   the  __p___________________________  
roject?  Select  any/all  that  apply.  
esearch/evaluation  
ther   ___________________________  
ᴏ      ELGBTTQA   mployment   s kills/preparation   ᴏ      O R ther  ____________________________  
educing   discrimination/racism  
ᴏ  Which  
   Social   o inclusion  
f   t he   f ollowing  and  social  
f ocus  supports  
a reas   w ill   b e   i ncluded   ᴏ      Aiging   n   t independence  
he   p roject?   Select  any/all  that  apply.  
ᴏ      N Homeless/Sub-­‐standard  
utrition/food   security   housing   ᴏ      O ther  ____________________________  
ᴏ  ᴏ        H   Eealth  
mployment   and  wellness   s kills/preparation   ᴏ  
ᴏ        PT  Rersonal  
ransportation  
educing  
choices/coping  
d supports  skills  
iscrimination/racism  
ᴏ  
ᴏ  ᴏ            A cademic  
C  Nrime   achievement/support   ᴏ      Housing  supports  
Which   of  rteduction  
utrition/food   he  following   security  focus  areas  will  be  included   ᴏ        P  iPn   the  project?  
ersonal   choices/coping   Select  any/all   skills   that  apply.  
ᴏ      
3    Employment   A rts   a nd   c ulture,   t heatre,   m usic   ᴏ   ublic   a wareness/education  
ᴏ   skills/preparation   ᴏ  ᴏ        R  Heducing   sdupports  
iscrimination/racism  
ᴏ  ᴏ        S  Aport  
Which   cademic   he  rfaecreation  
of  atnd   chievement/support  
ollowing   focus  areas  will  be  included   ᴏ      Rin   ousing  
the  project?  
esearch/evaluation   Select  any/all  that  apply.  
ᴏ  ᴏ        N   Autrition/food  
rts   a nd   c ulture,   security  
t heatre,   m usic   ᴏ  ᴏ        P  Personal  
ublic   a choices/coping  skills  
wareness/education  
ᴏ      ESocial   mployment   inclusion   skills/preparation  
and  social  supports   ᴏ      R Aeducing  
ging  independence   discrimination/racism  
ᴏ  ᴏ        A  Scademic   port  aand   archievement/support  
ecreation   ᴏ  ᴏ        H ousing  
 Rransportation   supports  
esearch/evaluation  
ᴏ  
3     NH utrition/food  
ealth   nd   w s ecurity  
ellness   ᴏ  
3     P
T ersonal   c hoices/coping   supports  skills  
ᴏ  
ᴏ        A  Srts   ocial   and  i culture,  atnd  
nclusion   heatre,  
s msusic  
ocial   upports   ᴏ  
ᴏ        P  Aublic  
ging   aindependence  
wareness/education  
ᴏ      A Crime   cademic   achievement/support  
reduction   At  what  level  will  the  project  ᴏ  o  r    Heousing   vent  primarily  supports  occur?  
3
ᴏ  
ᴏ  
ᴏ  
     S  Hport   ealth   and  a recreation  
nd   w ellness   ᴏ  ᴏ        R  Tesearch/evaluation  
ransportation   supports  
3        ᴏA  rts    Individual  and  culture,     theatre,  music   ᴏ      Public  awareness/education  
           ᴏ    Family    ᴏ    Community  
ᴏ       S
ᴏ        S  Cport   ocial  
rime   i nclusion  
reduction   a nd   s ocial   s upports   ᴏ       A ging   i ndependence  
ᴏ  
3    Health  and  wellness   a nd   r ecreation   ᴏ       R esearch/evaluation  
ᴏ   ᴏ      Transportation  supports  
ᴏ      Social  inclusion  and  social  supports   ᴏ      Aging  independence  
ᴏ      Crime  reduction  
ᴏ      Health  and  wellness   ᴏ      Transportation  supports  
ᴏ      Crime  reduction  At  How   what  level  will  the  project  or  event  primarily  occur?  
often  will  participants  take  part  in  the  project?  
       ᴏ    Individual                ᴏ    Family    ᴏ    Community  
       ᴏ    One-­‐time  event   At  what  level  will  the   ᴏ    p Droject  
aily   or  event  primarily  occur?    ᴏ    Weekly  
               ᴏᴏ        IM onthly      
ndividual   ᴏ      O    ther   ________________________________  
   ᴏ    Family    ᴏ3    Community  
At  what  level  will  the  project  or  event  primarily  occur?  
       ᴏ    Individual                ᴏ    Family    ᴏ    Community  
At  How  
what  olften  
evel  w will  
ill  pthe   project  otr  
articipants   ake   event   pirimarily  
part   n  the  project?   occur?  
         ᴏ  ᴏ      I  ndividual   One-­‐time     event   ᴏ        D      aily  
ᴏ    Family    ᴏ    Weekly    ᴏ    Community  
       ᴏ    Monthly     How   o ften   w ill   p articipants  
3  Other  _Twice
ᴏ   t ake  
_______________________________   p art  
a month i n   t he   p roject?  
       ᴏ    One-­‐time  event   ᴏ    Daily    ᴏ    Weekly  
       ᴏ    Monthly     How  often  will  participants   ᴏ    Other  _t_______________________________  
ake  part  in  the  project?  
       ᴏ    One-­‐time  event   ᴏ    Daily    ᴏ    Weekly  
How  often  will  participants  take  part  in  the  project?  
       ᴏ    Monthly  
Community   Initiatives     Fund   ᴏ    Other  _5  _______________________________  Jan 2017
       ᴏ    One-­‐time   event   ᴏ    Daily    ᴏ    Weekly  
       ᴏ    Monthly     ᴏ    Other  ________________________________  
 Project  Activities  and  Timelines  
Indicate  the  primary  or  major  types   Project   Activities  
of  activities   and  
that   wTill  imelines  
occur  to  carry  out  the  project  and  their  
Indicate   t he   p rimary   o r   m ajor  
anticipated  start  and  end  dates.   t ypes   o f   a ctivities   t hat   w ill   occur  to  carry  out  the  project  and  their  
anticipated  
Activity   start  and  end  dates.  
Description   Start  Date   End  Date  
Activity  
One Description  
recreational event per month. Light meal provided Start  
Dec 1/16Date   End   Date  
Nov 30/17
One hip-hop/break dance class per month. Light meal provided Dec 1/16 Nov 30/17
Monthly mentorship sessions with the planning committee Dec 1/16 Nov 30/17
Recruitment/orientation/training meetings and workshops with volunteers Dec 1/16 Nov 30/17
Evaluation meetings held with planning committee, participants and volunteers mid-way through project June 1/17 June 8/17
Program evaluation at the end of the project. Nov 23/17 Nov 30/17
This is an
importan
step that t
shows the
committe
e reviewin
the applic g
ation tha
you have t
a well
thought o
ut plan fo
your proje r
ct.

Expected  Results  
Estimate  the  number  of  people  that  will  Expected  
participate  Results  
and/or  benefit  from  the  project.   60
Estimate  tthe  
Describe   he  enxpected  
umber  oof  utcomes,  
people  that   will  participate  
benefits,   and/or  
or  results   benefit  from  
that  participants   the  
will   project.  
gain   from  their  
Describe   t he   e xpected   o
involvement  in  the  project.  utcomes,   b enefits,   o r   r esults   t hat   p articipants   w ill   g ain   from  their  
involvement  in  the  project.  
30-40 Members with disabilities will have access to monthly social and recreational
activities as well as monthly hip-hop dance classes. Friendships, increased confidence, and
social capacities will increase, all of which contributes to self-reliance and empowerment.
2-3 members with disabilities will build employment and leadership skills though mentorship.
10-20 young adults (primarily individuals without disabilities) will gain experience in
community inclusion by assisting with events and forming meaningful relationships
with peers with disabilities.

How  will  you  measure  and  evaluate  the  overall  success  of  your  project?  How  will  you  evaluate  
How  
the   will  you  
results   measure  and  
experienced   by  pearticipants?  
valuate  the  o   verall  success  of  your  project?  How  will  you  evaluate  
the  
A results  experienced  
questionnaire will be bcompleted
y  participants?  
by all   participants at the beginning, midway, and end of
the project. This will ask for their feedback on their enjoyment of the activities, but also on how
they feel their social skills and inclusion in the community have changed.
We will also hold focus groups three times throughout the year with current and potential
members as well as volunteers to discuss how inclusive their schools, workplaces, and public
spaces are. This information will help us to determine if members are seeing a change to a
more inclusive community, and where more work is needed.
Finally, we will track attendance at each event so we know how many people are attending
and returning to our events.
Recognition  of  the  CIF   Evalu
ati
Recognition  
If  a  grant  is  awarded,  describe  how  you   of  the  
will  recognize   CIF  
the   Community  Initiatives  Fund.   piece that osn is an importa
n
The
If  a  gCIF will
rant   is  abe recognized
warded,   as a hsupporter
describe   inill  our
ow  you  w quarterly
recognize   Community  Initiatives  Fund.   will report ohnows how you t
the  newsletters,
you a the ou
social media (Facebook and Twitter), website, and advertising materials. rep
chieve
in you
tcome
ort, an
s
d can r fina
future l
help s
fundi ecure
succes ng if
sful. you a
Community Initiatives Fund 6 Jan   2017 re
Community Initiatives Fund 6 Jan  2017
 BUDGET  INFORMATION  
Provide  all  estimated  revenues  tBUDGET   hat  will  support   INFORMATION  
the  project.  Indicate  for  each  applicable  
revenue  source(s)  the  budgeted  amount  and  if  the  revenue  is  confirmed  or  pending.  
Provide  
Revenue   all   estimated  revenues  that  will  support  the  project.  
Source(s)   $  AIndicate  
mount   for  eConfirmed  
ach  applicable   Pending  
revenue   s ource(s)   t he  
Municipal  Government  (RM, Town, City)   b udgeted   a mount   a nd   i f   t he   r evenue   i s  
5,500 c onfirmed   o r   p 3
ending.  
ᴏ   ᴏ  
Revenue   S ource(s)  
Provincial  Government   $   A mount   Confirmed  
ᴏ   Pending  
ᴏ  
Municipal   G
Federal  Government  overnment   ( RM, Town, City)   ᴏ  
ᴏ   ᴏ  
ᴏ  
Provincial  
Community   Government  
Development  Corporation   ᴏ  
ᴏ   ᴏ  
ᴏ  
Federal   G overnment  
United  Way/Community  Foundation   ᴏ  
ᴏ   ᴏ  
ᴏ  
Community   D evelopment  
Corporate/Business  Sponsorship   C orporation   1,100 3
ᴏ  
ᴏ   ᴏ  
ᴏ  
United   W ay/Community  
Registration  Fees   F oundation   ᴏ  
ᴏ   ᴏ  
ᴏ  
Corporate/Business  
Fundraising   S ponsorship   ᴏ  
ᴏ   ᴏ  
ᴏ  
Registration  
Donations   Fees   ᴏ  
ᴏ   ᴏ  
ᴏ  
Fundraising  
Other   ᴏ  
ᴏ   ᴏ  
ᴏ  
Donations  
Community  Initiatives  Fund  Request   14,500 ᴏ  
ᴏ   3
ᴏ  
ᴏ  
Other  
Total  Revenue  Budget   $   21,100 ᴏ   ᴏ  
Community  Initiatives  Fund  Request   ᴏ   ᴏ  
Total   R evenue   B udget  
Provide  all  estimated  expenses  for  the  project.  Indicate  the  expenses  that  CIF  is  being   $  
Provide all testimated
requested   o  support,  Expenses and  the  afor the project.
mount   of  the  rIndicate
equest.  the expenses that CIF is being requested
to support,
Provide  
Expense   aIll   eand
tem   the amount
stimated   expenses  of the for  request.
Description   the  project.  Indicate  the  expenses   that  CIF  is  being   $  CIF  
$  Expense  
Expense
requested   Item Description
to  support,  and  the  amount  of  the  request.  
Staff  Salaries/Benefits   $ Expense $ CIF
Expense   Item  
Staff Salaries/Benefits
Honorariums/Fees   Description  
Part time Program Coordinator $  Expense   7,200 $  C6,000 IF  
Staff   S alaries/Benefits  
Instructor Fees
Entertainment   Hip Hop Dance Instructor 2,000 1,500
Honorariums/Fees  
Project  
EntertainmentSupplies   DJs for special nights 500 500
Entertainment  
Equipment  
Project Supplies Rental   Craft/activity supplies 1,200 400
Project  
Facility  
Equipment S upplies  
Rental   Rental
Equipment   Rental  
Advertising/Promotion   Bowling alley, rec centre, other venues for
Facility  
Volunteer  Rental  
Facility Rental Recognition   weekly activities 1,200 1,200
Advertising/Promotion  
Food/Nutrition  
Advertising/Promotion Posters and ad in local newspaper
Volunteer   Recognition  
250 150
Other   0
Volunteer Recognition Volunteer appreciation lunch
Food/Nutrition   250
Other  
Food/Nutrition
Other   Healthy csnacks
Overhead   at each
osts  include   items  sevent uch  as   1,800 1,050
Overhead  
Other overhead  
Other  
General   Transportation
supervision,   accounting   of participants
fees,  administration,   1,200 800
expenditures  up  to  a   insurance,   r ent,   r epairs,   office  supplies,  
Overhead   Overhead  
Office rental, c osts   i nclude  
utilities, i tems   s uch   a s  
supervision, insurance,
telephone,   utilities,   and  fundraising  
Overhead
maximum  
General  
of  20%  of  the  
overhead   supervision,  accounting  fees,  administration,  
supervision
expenses.   I nvoices   o r   r eceipts   for  overhead  
6,000 2,900
approved  grant  amount  are   insurance,   r ent,   r epairs,   o ffice   s upplies,  
expenditures  up  to  a   costs  are  not  required  to  claim  overhead  
eligible.
Total Expense
maximum   Budget
of  20%  of   the   telephone,  utilities,  and  fundraising  
expenses,  but  are  only  allowed  under  this  
$ 21,600 $ 14,500
approved  grant  amount  are   expenses.  Invoices  or  receipts  for  overhead  
category.    
eligible. costs  are  not  rT he Bu to  claim  overhead  
equired  
dget c
Total  Expenses  Budget   expenses,  but  aanre  
exopnly   olum
ensaellowed   under  
n forthis   $   $  
category.     include th item shoul
progr e tota d
am l cos
Total  Expenses  Budget   to CIF , and the t to the $   $  
rtant
c
CIF fu olumn is h quest
Re
i s v e r y impo atch
It m
nding ow mu
venues
use fo
r you p
l
ch that Re and the
could that expens a7n to ses, 2017 is the
Community Initiatives Fund be the e, whi ExpenJan   the CIF
or jus w ch s t t o
t a po hole amou requ e
!
rtion. nt in both
sameJan  
Community Initiatives Fund 7 2017
 s and
ntribution
In-kind co
volvem t en
volunteer in t from your
ppor
Other  Contributions   indicate su re you
y. Make su
3    Yes    ᴏ    No   communit
Will  any  in-­‐kind  goods  or  services  be  cOther   Contributions  
ontributed   to  the  project?            ᴏ include it he
re, an d n ot in
Will  
If   any  
yes,   in-­‐kind  the  
indicate   goods   or  services  
type(s)   be  contributed  
of  contributions   to  the  project?  
and  approximate            ᴏ    Yes  
value.    ᴏ    No   the budget .
If   y es,  
Contributor   i ndicate   t he   t ype(s)   o f   c ontributions   a nd   a pproximate   v
Description  of  Contribution  alue.   $  Value  
Contributor  
Local businesses Description  
Gift cards, books, of  movies,
Contribution  
etc. for door prizes at events $  V alue  
300
Local sports teams and culture organizations Free tickets/entrance fees to events 1,200

Will  volunteers  be  involved  in  planning  and/or  delivery  of  the  project?            ᴏ 3    Yes    ᴏ    No  
Will  
If   volunteers  
yes,   indicate  tbhe  
e  ianvolved   in  planning  
pproximate   number   and/or   delivery  of  the  project?            20
of  volunteers.   ᴏ    Yes    ᴏ    No  
If   y es,   i ndicate   t he   a pproximate   n umber   o f   v olunteers.  
Provide  a  brief  description  of  how  the  volunteers  will  be  involved  in  the  project.  
Provide  a  will
Volunteers brief  
assistdescription  
with the o f  how  the  
planning and volunteers  
execution of will  
each be  monthly
involved   in  the  
event and project.  
dance class. There will
also be volunteers paired with program participants to support them in successfully engaging in each event.

APPLICANT  DECLARATION  
APPLICANT  DECLARATION  
To  complete  your  application,  you  must  confirm  that  you  understand  and  agree  with  all  of  the  
To  complete  
following   your  application,  you  must  confirm  that  you  understand  and  agree  with  all  of  the  
statements.  
3 I  have  carefully  read  and  understand  the  eligibility  criteria  for  this  program  as  described  in  
following  
ᴏ   s tatements.  
ᴏ   I  the  
have   carefully  G
application   read   and  understand  
uidelines,   and  I  confirm   the  tehat  
ligibility  
the  ocrganization  
riteria  for  this   program  maeets  
I  represent   s  described  
these   in  
the  application  Guidelines,  and  I  confirm  that  the  organization  I  represent  meets  these  
criteria.  
3 criteria.  
ᴏ   I  understand  that  the  organization  I  represent  is  not  eligible  to  apply  to  this  program  until  
ᴏ   I  any  
understand  
outstanding   that   the  oRrganization  
Final   eports  for  CIIF    represent  
grants  have   is  nbot   eligible  
een   to  apply  
submitted   to  atpproved.  
and   his  program  until  
3 any  
ᴏ   outstanding  
I  accept   the  conditions   Final  Roeports  
f  this  pfor   CIF  grants  
rogram   and  ahgree   ave  bto   een   submitted  
accept   the  CIF  aB nd   approved.  
oard’s   decision.  
3 I  I  caonfirm  
ᴏ  
ᴏ   ccept  the   conditions  
that   of  othis  
to  the  best   f  mpy  rogram  
knowledge   and  tahe   gree   to  accept  itn  he  
statements   CIF  
this   Board’s  decision.  
application   are  
ᴏ   I  complete  
confirm  tahat   t o   t he  
nd  accurate.   b est   o f   m y   k nowledge   t he   s tatements   i n   t his   a pplication   are  
3 complete  
ᴏ   I  agree  that   and  
the  accurate.  
organization  I  represent  will  return  a  portion  or  all  of  the  funding  if  the  
ᴏ   project  
I  agree  tihat   the  
s  not   organization  
carried   out  as  dIescribed  
 represent   in  w ill  raeturn  
the   pplication.  a  portion  
  or  all  of  the  funding  if  the  
3 I  agree  that  a  completed  Final  Report  including  financial  v  erification  will  be  provided  to  
ᴏ   project   i s   n ot   c arried   o ut   a s   d escribed   i n   t he   a pplication.  
ᴏ   I  CIF  
agree   that  
within   a  dcays  
60   ompleted   Final  Report  
of  completion   including  
of  the   project.  f  inancial  
  verification  will  be  provided  to  
3 CIF  
ᴏ   I  have  within   60  d/ays  
printed   of  completion  
 downloaded   a  copy  of  tohe  
f  opur  
roject.      
completed   application.  
ᴏ   I  ohf  ave  
Name   printed  /R  depresentative  
Authorized   ownloaded  a  c(please opy  of   our     completed  
print) application.  
Position  
Name  
Jane Smith o f   A uthorized   R epresentative   ( please print)   Position  
Executive Director
Signature   Date  
Signature   Date  
October 1, 2016

Complete  and  submit  your  application  on-­‐line  at  [Link].  

Complete  and  submit  your  application  on-­‐line  at  [Link].  

Community Initiatives Fund 8 Jan 2017

Community Initiatives Fund 8 Jan 2017