Leadership Development for Racial Equity Funding Application

Application deadline: May 2, 2016, at noon

Application Cover Sheet

Read Application Instructions and Criteria and Proposal Writing Tips carefully before completing this application. To complete this form, save this document in Microsoft Word and type into each shaded field; click to select a check box. Use the TAB key to move from field to field, or click in each field.

Applicant Information (IRS qualifying organization; use legal name as registered with the IRS)

Organization
Addres
Department or Project, if applicable
Address
City / State / Zip Code
Phone / Ext / E-mail
CEO/Director / Title
Tax Exempt ID#
Web site / www.
Project Contact / Title
Address
City / State / Zip Code
Phone / Ext / E-mail

Proposed Activities Summary Information

Project Name:

Racial/Ethnic Population(s) Organization Serves ((Check the box for each population served by the organization and, in the space that follows each population group that you check, provide your best estimate of the % of the overall population that identify as that race/ethnicity)

African-American/Black: % Asian-American/API: % Latino/Hispanic: %

Native American: % White: % Other (specify: ) %

Brief Description of Proposed Activities (limited to 190 characters). Grant funding will be used:
To
Start Date / July 1, 2016 / End Date / March 31, 2017
Amount Requested / (enter an amount from $5,000 to $10,000)

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Geography That Will Be Affected

Organization serves in all 32 eligible counties listed below:

Yes No

If no, indicate in the space next to the county’s name the percentage of the organization’s services that take place there (best estimate).

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Center for Health Program Management

Alpine %

Amador %

Butte %

Calaveras %

Colusa %

El Dorado %

Fresno %

Glenn %


Kings %

Lassen %

Madera %

Mariposa %

Merced %

Modoc %

Mono %

Nevada %


Placer %

Plumas %

Sacramento %

San Joaquin %

Shasta %

Sierra %

Siskiyou %

Solano %


Stanislaus %

Sutter %

Tehama %

Trinity %

Tulare %

Tuolumne %

Yolo %

Yuba %

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Indicate if the proposed activities serve an urban or rural area, or both (see page 3 of the Application Instructions and Criteria for instructions on determining this).

Serves only an urban area Serves only a rural area Serves both urban and rural areas

What percent of people served by the proposed activities live in a rural area? (Best estimate; see page 2 of the Application Instructions and Criteria for instructions on determining rural areas.) %

Application Materials Checklist

Submit all documents in PDF format.

Completed Capacity Building/Leadership Development Funding Application form, which includes:

§  Application Cover Sheet

§  Proposal Narrative (limit to 3 pages)

§  Budget and Budget Explanation

§  Performance Measures

501(c)(3) determination letter

Most recent annual financial statement that shows revenue and expenses for a full year (not IRS form 990)

Submit all materials in the checklist above by attaching them to an e-mail in PDF format and sending to .

Include the applicant organization name and the telephone number of the person sending the application e-mail in the body of the e-mail so we can contact you if we have questions.

Name of authorized 501(c)(3) officer
Title

Please answer each of the following questions completely and succinctly using this form. Limit your Statement of Qualification and Proposed Use of Funds responses to no more than three pages. The three pages does not include the Proposed Budget and Budget Explanation, financial statement or your 501(c)(3) determination letter.

Statement of Qualification

1. Briefly describe a) your organization’s mission, its youth focus and its work to reduce health disparities and address racial equity; b) how long it has served the community; c) the ethnic makeup of your organization’s executive staff and board; d) whom you serve, including the number, age, gender, ethnicity, socioeconomic situation, where they live and special circumstances; e) a brief overview of the types of programs you provide; and f) examples of notable successes in your organization’s work with youth.

2.  Explain your organization’s interest in policy and systems change-related organizational capacity building and/or leadership development and how your organization will be better able to address institutional and/or systemic racism as a result.

3.  Describe your organization’s readiness for policy and systems change-related capacity building or leadership development work to promote racial equity.

Proposed Use of Funds

4. Describe how you plan to use these funds for policy and systems change-related organizational capacity building or leadership development activities to address racial equity.

Don’t forget to complete the Proposed Budget and Budget Explanation.

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CENTER FOR HEALTH PROGRAM MANAGEMENT

PROPOSED PROJECT BUDGET AND BUDGET EXPLANATION

Do not enter in-kind resources on this form. Describe in-kind in the Budget Explanation.

Project Start Date: / July 1, 2016 / Project End Date: / March 31, 2017
Total
Project Budget / Requested from Sierra Health Foundation / Other Funding Committed to Project (if applicable)
I. Personnel
Salaries (list position) / FTE
1
2
3
4
5
6
Payroll Taxes and Benefits
Total Personnel
II. Other Expenses
Consultant Fees
Office Supplies
1
22
3
4
Postage
Printing/Duplicating
Information/Materials
Equipment
Rent/Utilities
Travel
Miscellaneous (list)
1
2
3
4
5
6
Total Other Expenses
Indirect (up to 15% of direct costs)
Total Grant Expenses


BUDGET EXPLANATION

For each item, explain how the funds will be used for the project, including other funding committed to the project and the source of other funding. Describe in-kind resources.

Shaded field will expand as you type and continue on to additional pages.

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Leadership Development for Racial Equity Application

Performance Measures

All grantees will be required to report on key performance measures for their grants. In the following table, you are asked to identify (1) key activities that will be carried out in order to implement the project, (2) the expected outputs of those activities, and (3) the goals, or expected outcomes, of the project. For example, key activities could include conducting trainings or organizing community meetings, among other steps. Examples of the expected outputs of activities include the number of trainings and/or community meetings and the number of people or organizations that are expected to participate. The activities and expected outputs are ways of measuring progress toward the goals. The expected outcomes of the project identify how the project will make a difference in the short-term. Examples of goals include development of a cadre of youth leaders, increased awareness of water quality issues in neighborhoods of color, increased organizational communication skills to speak to system leaders, among many other possibilities. For the performance measures table, identify the extent of change that you expect to achieve and the ways in which the change(s) could be measured.

Fill in the table below with your best estimate of the proposed activities, outputs and expected outcomes. As you identify performance measures for the proposed project, consider how, when and where the data will be collected and who will collect it.

This table will expand as you type and continue on to additional pages.

Brief Purpose of Project (limit to 190 characters and should be the same as stated on the cover sheet):

Key Activities / Activity Outputs / Expected Outcomes / Planned or Potential Outcome Measures
What will you do? (List major activities specific to the Leadership Development for Racial Equity (LDRE)funded capacity building and leadership project) / How much will you do? (List outputs in terms of numbers of activities performed or people engaged) / What do you expect to achieve as an immediate or direct result of the project? (Describe the ways your organization and those involved in the activities will be different in terms of capacity to carry out policy and systems changes that advance racial equity.) / How will you know the extent to which you have achieved the expected outcome(s)? (List the ways in which you will measure changes identified as expected outcomes, such as through documentation, participant feedback forms, interviews, etc.)
Long-term impact: If your project is successful, what is the long-term impact on you, your organization and the communities you serve?

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