IDENTIFY APPLICATION TYPE:

COMMUNITY PROJECTS/PROGRAMS
INDIVIDUAL RECIPIENT

PART A:

1. / Wheels In Motion Event Community:
2. / Contact Information (for the individual completing this form)
Mr. Mrs. Ms. Dr. / First Name: / Last Name:
Organization: (if applicable) / Title:
Mailing or Street Address:
City: / Province: / Postal Code:
Telephone Number: / Fax Number: / Email Address:
Preferred Language of Correspondence:□ English□ French
Signature:
3. / Project Title:
4. / Estimated Total Project Cost:$ / RHWIM Portion of Total Cost:$
5. / Budget details, please attach quotes if available. Identify other organizations potentially contributing funding resources or in-kind contributions, the value of the contribution, and contact information (name, phone or email).
6. / Please provide a description of the proposed project or program in 200 words or less.
a)For an individual project or program, please describe the need of the individual, a description of the item to be purchased, work to be done, service or program and some basic information about them (i.e., gender, type and level of injury/disability, and approximate age).
b)For a community project or program, please include the following: who, what, where, when, as well as the impact this project or program will have to improve quality of life of people with spinal cord injury.

PART B: (To be completed by Provincial/Regional/Local Solutions TeamSolutions Rep)

Sponsoring Organization:
The Rick Hansen Foundation requires that a sponsoring organization be selected to administer the grant funding. This organization must be sufficiently connected to the project to enable administration and reporting of the funding and accountability for the project’s completion. Further, this organization must be a “Qualified Donee” as defined by the Canadian Income Tax Act 149.1(1).
Note:Number will be XXXXX XXXX RR XXXX. Registered Municipalities do not require a Charity Business Number.
Preferred Language of Correspondence:□ English□ French
Organization name: / CRA Charitable Business Number:
Contact name: / Position:
Address:
(street & mailing addresses required)
Phone number: / E-mail:
Recipient Name (if different than above): / Recipient Telephone/Email:
Recipient Address:
If this project is to fund an individual, consent to use personal information must be signed by the individual recipient or designate.
The Rick Hansen Foundation (”RHF”) or designate may use and keep a record of any personal information relating to this grant application for the purposes of processing this application, and may disclose this information as needed to other parties for the purposes of evaluation, approval and administration of this grant. RHF or designate will not share this personal information with any other parties for purposes unrelated to this grant application, except as required by law.
Signature of consent received from: / Date Signed:

PART C:(To be completed by Provincial/Regional/Local Solutions Team)

Having reviewed this Quality of Life Application, the Provincial/Regional/Local Solutions Team recommends the proposed project be approved.
Name (please print) / Signature of Regional/Provincial/Local Solutions Team Designate
Date

Please submit by email, fax ormail, to:

Contact:Manitoba Provincial Solutions Team

c/o Canadian Paraplegic Association (Manitoba) Inc.

Room 211 – 825 Sherbrook Street

WinnipegMB R3A 1M5

Phone: (204) 786-4753

Fax: (204) 786-1140 Email:

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