PA Healthy & Green Mini-Grant Application Worksheet Section 1: Applicant Information

PA Healthy & Green Mini-grant Application Worksheet
section 1: Applicant Information

Amount Requested (up to $5,000):
Average Number of Children Served Daily: Number of Staff:
Age Range of Children Served in Program: Annual Operating Budget:
Children cared for in lower-level or basement of facility: yes or no (circle one)

Program Name:

Primary Contact and Title:

Address: Phone: Fax:

Website: Email:

DPW License / Certificate Number: MPI # Keystone STARS Level

Regional Key (as of July 1, 2013): County:

Currently NAEYC or NAFCC Accredited: Yes or No (circle one) _____Center or Group Provider
Head Start Provider: Yes or No (circle one) _____Family Home Provider
Own Facility: Yes or No (circle one) Lease or Rent Facility: Yes or No (circle one)
Do you have the authority or have you received permission from a building owner/landlord to implement all items or services requested in this proposal? Yes or No (circle one)
Signature and Title of Authorized Official:
Attendance in Eco-Healthy Childcare Professional Development: Date:
Certificate Attached: Yes or No (Circle One)
Name and Title of person who attended:
Attendance in (Project Learning Tree and/or Growing Up WILD)Professional Development: Date:
Certificate Attached: Yes or No (Circle One)
Name and Title of person who attended:

Plan to become certified by Eco-Healthy Child Care© with this grant: Yes or No (Circle One)
Name and title of authorized person responsible for this application.

Date Print Signature

PA Office of Child Development and Early Learning: Request for Proposal 7 | Page

SECTION 2: PROGRAM DESCRIPTION
Please describe your program and its commitment to children’s environmental health. (250 words or less).

SECTION 3: GRANT Budget Summary

Eco-Healthy Child Care Requests: Amount Requested

Supplies (list)
Equipment (list)
Furniture (list)

Testing Services (provide copy of invoices)
Other Types of Services (please list and provide **estimates)
Other (please list)

SubTotal

Environment & Ecology Materials (total dollar requested)

Total Grant Funds Requested

** Obtain a minimum of two qualified comparative written price quotes or estimates for any single purchase or professional service the PROVIDER makes with grant funds with an estimated cost of $3,000 or greater. These price quotes must be maintained as part of the recordkeeping files. In the event the PROVIDER chooses not to select the lowest price quote, the PROVIDER must create a written justification and maintain this justification with its records for audit purposes.”

SECTION 4: Program Status with Eco-Healthy Child Care Checklist©

Directions:

1) If you have already completed the checklist item, place an X on the line preceding the word, “Completed”.

2) If you are unable to complete a checklist item, place an X on the line preceding the word “Incomplete”. It is not necessary to complete every checklist item. Please provide a brief explanation of why you are unable to complete these items.

3) If you are planning to complete a checklist item should you receive assistance from this mini-grant, place the requested dollar amount on the line after the words “Total Cost”. Describe how you will complete the checklist item. (Items 1, 6, and 11 are required).

Keep your answers brief and in bulleted format. See the document called PA Healthy & Green Mini-Grant Application Tips for sample ideas and an example of how to provide information on the status of each checklist item.

Pesticides and Pest Prevention
Completed ______Incomplete Total Cost______

1. We use non-toxic techniques both inside and outside the facility to prevent and control pests (both insects and weeds). If a serious threat remains and pesticide application is the only viable option, parents and staff are notified in advance and a licensed professional applies the least toxic, effective product at a time when children will have the least exposure to the application area for at least 12 hours (see manufacturer’s instructions to ensure 12 hours is enough time). REQUIRED