Central Ohio Area Agency on Aging

(COAaa)

APPLICATION FOR 2018PROGRAM FUNDING UNDER TITLE III-D OF THE OLDER AMERICANS ACT AMENDMENTS OF 2006

I. A. FACE SHEET

  1. Applicant Agency
Applicant Name:
Address:
City, Zip Code:
Telephone:
FAX:
E-Mail: /
  1. Type of Agency
Public:
Private Nonprofit:
Private For Profit: /
  1. Applicant Agency Funded by COAAA in 2017?
Yes:

No:

4. Federal Tax ID No:
5 Program Period:
January 1, 2018 Thru December 31, 2018
6. NAME, TITLE, ADDRESS OF PROGRAM STAFF TO WHOM CORRESPONDENCE SHOULD BE MAILED:
7. PRINTED NAME AND TITLE OF INDIVIDUAL AUTHORIZED TO SIGN CONTRACT ON BEHALF OF ORGANIZATION:
8. SIGNATURE OF INDIVIDUAL AUTHORIZED TO SIGN CONTRACT:
9. DATE OF SIGNATURE:

Narrative Questions for 2018Title III-D Grant Funds

Evidence-Based Programs

Name and title of individual responding to these questions: ______

Date ______

Please describe how you will implement a minimum of two (2) Healthy U and/or Matter of Balance workshops of any combination to reach 20 completers before December 31, 2018. Include in your response the following information:**

1) Names of current, certified Healthy U or Matter of Balance leaders/coaches (10 points for active trainers available immediately; 5 points for identifying leaders/coaches who need to be trained):

2) Anticipated time frames for completing each of the two workshops, avoiding holidays and potential weather issues (5 points):

3) Plan for targeting and recruiting participants, including promotional efforts you will use such as print, media, in-person presentations (20 points):

4) Names of other organizations you will partner with in implementing these workshops. Are these existing partnerships or will you need to develop these partnerships? Describe specifically how you will be partnering with them (15 points):

5) Potential locations for each workshop, remembering that they must be accessible for individuals with physical impairments (10 points):

6) Plans, if any, for providing incentives (e.g. gift cards, water bottles) for participants who attend. (5 points):

7) How will you strive to reach at least 20 completers during the year? (Healthy U completer is a participant attending 4 of 6 sessions; MOB completer is one who attends 5 of 8 sessions) (10 points):

8) Please identify how you will use these grant funds, i.e. promotion, staff time, class materials? Itemize as much as possible. (20 points):

9) Any other information you wish to provide that describes how you will implement these workshops. (5 points):

**Points listed after each question are maximum for that question. Total points available = 105, including items noted below:

Application Face Sheet (2.5 points)

Organization has received and expended these grant funds in a previous year (2.5 points)