Health Projects Grant Application
Return completed application to:
Chair, Eastern Kings Memorial Health Foundation
23 Earnscliffe Avenue, Wolfville, NS B4P 1X4
(902) 542-2359
(Please use only this application and complete in full.)
Project Name:
OrganizationApplying:
Address:
Telephone # : E-mail :
Contact Person: Job Title:
When did your organization get started?:
You must have a charitable tax number in order to apply for funding; please list here.
1.Do you receive ongoing funding from a government source?Yes No
If yes, from whom and how much?
2.If your organization is already established, describe what it does for the community.
3.What have you done to identify the need that exists in your community for your project?
4.Target Group
Who will benefit from your project?
Describe their age, where they live and other characteristics that you know about them.
5.Goal
a)What is the goal of your project?
b)When does the project begin and end?
Begin:
End:
6.Project Objectives
What specific activities will you or your group do to meet the goal of the project?
7.Evaluation Plan
a)How will you make sure the project has done what you said it would do?
b)How will you know when your objectives have been met?
8.Staffing
Will people be paid using Foundation money to do the work of the project? Yes No
a)If yes, what knowledge and skills will they need to do the work?
b)How much time will they need to work on the project? How much will they be paid?
9.Community Support
a)Does your project use or build on existing community resources?
b)How do you feel this request for funding contributes to the health of the Eastern Kings Memorial catchment area? Please be specific.
10.Continuing Support
Describe how you plan to continue the project after your grant money is spent. If more money is needed,
where do you expect to get the money? Who will continue to be involved?
11.Public Recognition
Should the Foundation fund this grant in what ways will your organization publicly recognize the
Eastern Kings Memorial Health Foundation?
12.References
Please provide references other than members of Board or Staff who could speak on behalf of your
organization, its aims, objectives and accountability. References must be advised by you that they may
be contacted.
13.Consent
I/We hereby give permission to The EKM Health Foundation or its agents to verify any and all
statements made in this application, to contact project beneficiaries, Board, Staff, references and to announce publicly any support which may be provided.
______
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(Signature of Applicant)Signed on behalf of: (Name of Organization)
The applicant acknowledges that no commitments or promises have been made and that submission of this application is voluntary, without condition, and that the position of the Foundation is not contestable.
I certify that the information in this application is correct and complete in every respect and that information can be sought from other sources to assist in the review process. If I am awarded a grant, I will agree to comply with the terms and conditions as identified in the letter of Agreement.
Signature of Senior Officer of Organization:
______
Name (please print)Title
______
DateOrganization
Foundation Use Only:
Received By: Reviewed By:
Recommendations:
For further information, please contact the Administrative Assistant at (902) 542-2359.
Revised 02/2006