Missouri’s Blueprint Coalition for Safer Roadways

Central District

Application for Funding FY 2013

(July 1, 2012 to June 15, 2013)

Community Outreach

Mail completed applications to:

Missouri Coalition for Roadway Safety

c/o MODOT

Attn: Dianna Johnson

1511 Missouri Blvd. • P.O. Box 718

Jefferson City, MO. 65559

Or

Email completed applications for funding to

Questions: 573-522-1061 or 573-659-0789

REGION: / Central District
Contact Person:
(Please Print)
Phone:
Fax:
Email:
Address:

The Central District of the Missouri Coalition for Roadway Safety is accepting requests for sponsorships, grants for Project Graduation, alternative prom events and school docu-dramas, law enforcement equipment and events and other activities that encourage safe driving.

Project: ______Project Graduation

______Alternative Prom Event

______Docu-drama

______Law Enforcement Equipment *

______Law Enforcement Check Point*

______Other Law Enforcement______

______Other Request______

Total of Funds Requested $ ______

Please Note:

• Project Graduation and alternative prom events can receive up to $100 in grant funds and $100 in give-away incentives.

• School docu-dramas that demonstrate the effects of distracted driving, impaired driving and riding unbelted can request up to $700.

• Schools receiving Coalition funding must participate in the Battle of the Belt competition.

• Law enforcement receiving Coalition funds must participate and submit Dept. of Revenue Alcohol Influence Report and participate in the Missouri State Highway Patrol repository for DWI tracking system.

Name of Agency/School Involved:______

When is funding needed? ______

What agency/group will be the recipient of grant funds? ______

DESCRIBE SIZE of community/school/law enforcement agency to benefit from funding.

DESCRIBE PROPOSED EVENT—What is planned, when and where will it take place, how many people/students will be involved? Etc.

PROBLEM IDENTIFICATION—What problem will this event address and how do you know it is a problem?

PROJECT GOAL & DESCRIPTION—Clearly state your goal and identify: What needs to be done; who or what agencies will conduct the tasks; estimated timeframes (if known and if applicable)

RESULTS—What do you plan to accomplish? How will you determine whether this project was successful? (Give specific examples of how results will be measured.)

LAW ENFORCEMENT REQUESTS—IF APPLYING FOR EQUIPMENT OR CHECKPOINTS, did you apply for Missouri Highway Safety Grant funds? ______

Were you funded?______If you WERE funded, what were you funded for and what was the amount of the grant?______

BUDGET—What is total budget to complete this project? List all costs to complete this

project. If you anticipate any local match (in-kind services, donations, personnel), list these also.

I certify that this information in this request is true and accurate, to the best of my knowledge, and that any funds granted will be used as proposed and approved. I also agree to provide documentation as requested to certify use of funds and outcome of project.

I also agree that, as a recipient of grant funds, I and/or the organization I represent will make every effort to participate in the Central District Coalition or one of its subdistrict subcommittee meetings and/or I and my organization will serve as liaisons for information and assist with promoting Coalition activities within my community/school.

PREPARED by Signature:______

Title:______

Date:______

AUTHORIZED by Signature:______

Title:______

Date:______

Return to :

Missouri Coalition for Roadway Safety

c/o MODOT

Attn: Dianna Johnson

1511 Missouri Blvd. • P.O. Box 718

Jefferson City, MO. 65559

Or

Email completed applications for funding to

Questions: 573-522-1061 or 573-659-0789

(Please verify receipt of email)

Deadline: The Central District Coalition meets the second Tuesday of every month. Grant applications must be received by the 1st day of the month for consideration at that month’s meeting.

July 17, 2012

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