Mail to:
Dennise Albrecht, Partnerships and Advocacy CHEO, 401 Smyth Road, Ottawa, ON, K1H 8L1
Program/activity information: / Application filled out by:
Name / Name
Address / Title/role
Tel # / Tel #
Website
(if applicable) / Email
How long has your program or activity been in place? ______
Application Deadline: May 3, 2010
Select award category for which you wish to be considered (select one)Injury prevention / Mental health / Obesity / Poverty
Program/activity goals and objectives (max 200 words)
What inspired this initiative? What problem are you specifically addressing?
What are the goals and objectives?
Describe program/activity scope and services (max 200 words)
Describe your activities, whom you are targeting and why. How many kids and/or families are you reaching and how the problem is being addressed?
Describe program/activity challenges and resources (max 200 words)
What challenges have you faced? Who are your partners, staff or volunteers? What financial resources do you have?
Describe program/activity results (max 200 words)
Is your initiative sustainable? What has the program/activity achieved? How do you measure your results? What are you most proud of?
Thank you for completing the mail-in form.