Andover Cares Grant Request Application

1.  Background

The Andover Cares Fund (the “Fund”) is an arm of the Andover Rotary Charity Trust and was established to provide money, in the form of grants, to individual or organizations. The grants are to be used for address the opiate addiction epidemic in Andover (Merrimack Valley?). Special emphasis is being placed on education, prevention and treatment.

2.  Guidelines

·  The Fund will only consider grant requests that address the three areas of education, prevention and treatment.

·  The Fund will not fund private practices of individuals who provide services as a primary source of income.

·  The Fund will not fund activities or positions that are traditionally provided by the town.

·  Applications are accepted throughout the year on a rolling basis. Funding decisions are made within four weeks.

3.  Proposal

3.1.  Organization Information

3.1.1.  Organization name and contact information: address, contact person/title, phone number, email address.

3.1.2.  Date established

3.1.3.  Mission Statement

3.1.4.  Member information, including relevant education and experience

3.1.5.  Advisors

3.1.6.  Annual budget (Submit separate document)

3.2.  Application

3.2.1.  Amount requested

3.2.2.  Description of project

1.  One paragraph summary. Describe how this project fits a need that existing programs do not address.

  1. Target population. Be specific, e.g. 100 15-18 year olds that are deemed at risk by school counselors, police, AYS, friends, relatives and teachers.
  2. Estimate of fiscal impact. This is equal to the average benefit per person multiplied by the number of people served. The average benefit would be an estimate of costs such as:
  3. Cost of drugs per week times the number of weeks over the person might be dependent.
  4. Cost of lost wages from missing work
  5. Opportunity cost of not being able to move into a higher paying job
  6. Costs associated with arrest and/or punishment

3.2.3.  Budget. Include salaries, professional services, in-kind expenses.

3.2.4.  Other sources of funding. List organizations, their funding amount, scope of work and any potential overlap with AC funding.

3.2.5.  Key personnel. Include short biographies of any people who will be paid through the grant and any people who will serve as advisors.

3.2.6.  Activities. List and describe the key activities that this program will undertake and the time line of these activities. Provide a Gantt chart for the entire project. An example is shown below. Activities should match line items in the budget.

8/1 / 8/15 / 9/1 / 9/15 / 10/1 / 10/1 / 10/15 / 11/1
Distribute outreach materials
Select participants
Baseline Test
Therapy X
Interim Review
Therapy Y
Final assessment of participants
Final Report