Community Grant Application Form Step 1 of 7 14% Organization Information Organization Name ("doing business as")*Organization Legal Entity (if different than above)Website* Address*Organization Establishment Date (YYYY)*Number of Board Members*Number of Staff*Date of Last Organizational Plan or Review (YYYY)*Contact Information Applicant Name*Applicant Job Title/Role*Applicant Phone*Applicant Email* Program Lead Name (if different from above)Program Lead Title/Role*Program Lead Phone*Program Lead Email* Organization Lead Name*Organization Lead Title/Role*Organization Lead Phone*Organization Lead Email* Initiative Summary Initiative Name*Provide a maximum 150-word summary of your initiative in plain language. This summary may be posted publicly.*Choose one (1) of the following that best describes the life stage of this initiative:*Lights On (an existing initiative)Thrive (an existing initiative with some enhancements)Elevate (a completely new initiative)Which one (1) of the following impact areas does this initiative seek to address:*Early childhood developmentChild and youth mental healthRural and remote accessIdentify the health categories of the children/youth this initiative will support (choose all that apply):* Physical health challenges (acute) Physical disabilities (chronic/ongoing) Developmental disabilities Mental health challenges Significant risk of acquiring a disability or health challenge (please identify the risk below) Risk*Total Cost of Initiative (annual)*Funding Amount Requested (Year 1)*Funding Amount Requested (Year 2)*Funding Amount Requested (Year 3)*How many staff (will) run the program?*Do you have staff in place to run the initiative?*YesNoPlease identify staff and relevant skills and experience. (Maximum 3 staff working directly with the initiative)*What is your plan to ensure you have appropriate staffing in place? (150 word max)* Client Information Identify the intended client group(s) and expected number of clients to directly benefit from initiative: 0 to 6 (early years)*7 to 9 (middle years)*10 to 14 (middle years)*15 to 18 (youth)*19 to 24 (youth in transition)*Parents/Guardians*Specify the region(s) where the children, youth and families live that this initiative will support:* Capital Regional District Southern Gulf Islands Cowichan Valley Greater Nanaimo Port Alberni/West Coast Oceanside Comox Valley Campbell River & District North Island Describe how clients will be selected and how they will access the initiative. (100 word max)* Initiative Information Select the primary support/service focus:*TherapeuticSocial & Community EngagementTransition PeriodParent/GuardianSelect the intervention stage that best represents the impact of your initiative:*Prevention (addressing a health concern before it occurs)Early Intervention (intervening with a health concern in early stages)Intervention/Rehabilitation (addressing a health concern mid or late stage)Describe the need that will be addressed by the initiative; support this with some research. (250 word max)*Describe the approach you will use to deliver the initiative; this should include identifying the activities you’ll undertake. (250 word max)*List any research, evidence-based and innovative practices that inform program design. (10 max)*List any partnerships directly associated with this initiative. (10 max)* Initiative Evaluation Identify up to three (3) specific outcomes and the indicator(s), measurement tool(s) and goal(s) for each outcome. Refer to the explanatory notes at the end of the application for more information on outcomes measurement. Outcome 1*Outcome 1Access to appropriate and timely servicesLanguage and communication development and functioningCognitive development and functioningSocial and emotional development and functioningSocial connections and inclusion in communityPhysical and motor skill development and functioningLife skill development and functioningSuccess during transition periodsCaregiver knowledge and skills to support their children’s developmentFamily well-beingIndicator Measurement Goal 1*Outcome 2*Outcome 2Access to appropriate and timely servicesLanguage and communication development and functioningCognitive development and functioningSocial and emotional development and functioningSocial connections and inclusion in communityPhysical and motor skill development and functioningLife skill development and functioningSuccess during transition periodsCaregiver knowledge and skills to support their children’s developmentFamily well-beingIndicator Measurement Goal 2*Outcome 3*Outcome 3Access to appropriate and timely servicesLanguage and communication development and functioningCognitive development and functioningSocial and emotional development and functioningSocial connections and inclusion in communityPhysical and motor skill development and functioningLife skill development and functioningSuccess during transition periodsCaregiver knowledge and skills to support their children’s developmentFamily well-beingIndicator Measurement Goal 3* Financial Information Could the initiative proceed with partial funding?*YesNoWhat is the minimum contribution required to make this initiative feasible?Are there other risks that may impact your ability to deliver the initiative, including staffing, facilities, and other fund constraints? (100 word max)*Have you submitted your budget template?*YesNo Submission Confirmation Notification You will receive a confirmation by email to confirm this application has been submitted. The Foundation will provide notification of your application status no later than March 31st. Limited funding is available. Not all organizations that submit applications will receive funding, and successful applicants may not receive the full amount requested. The Foundation reserves the right to not fund any proposals in a given year.Authorization I confirm that I am an authorized agent of the applicant organization and have the full support of this organization to pursue a funding relationship with the Foundation.*YesNoI acknowledge that the Foundation may share the information contained in the application as described above for the purpose of vetting and decision-making*YesNoI give my permission to share application information with other community funders that participate in the funders’ networks on Vancouver Island if the Foundation feels it can leverage additional interest or contributions.*YesNoI give my permission for the Foundation to contact me or other named representatives in future regarding Foundation news, events and updates that pertain to the Foundation’s work in addressing child, youth and family health and well-being.*YesNoCompletion of Application Your application will be considered complete when this document is completed and the Foundation has received your complete budget; a template will have been emailed to you at the time you received the link to this application. If for some reason you did not receive the budget template or you have follow-up questions regarding your application, please contact the Community Investment Manager representing your region: South Island (Cowichan Valley, Capital Regional District, and Southern Golf Islands) Bronwyn.Dunbar@viha.ca 250-519-6921 Central/North Island (Port Alberni/West Coast, Nanaimo and north) Anita.Brassard@viha.ca 250-702-6131 Thank you for your commitment to the children, youth and families on the islands. This iframe contains the logic required to handle Ajax powered Gravity Forms.
