Rise Against Hungercrisis Request Form (With Instructions)

Rise Against HungerCrisis Request Form (with instructions)

When preparing the form, provide the most complete and recent information available. In addition, note the source of this data or information. If the information is not known, write, “Not known at this time.”

Applicant Organization Name:

· Prepared by (Name of person preparing the request form): ______

· Submission Date (Indicate the date that the request is being prepared): ______

1. Headquarters Contact Information

Primary Contact Person:
Mailing Address: (including postal code)
Email:
Phone Number:
Fax Number:
Website:
Where is your organization registered?
Date of registration:
Name and website of government agency which registered your organization:

2. Country Office (Field Contact Information)

Full Address of Country office (including postal code):
Primary Contact Name:
Title:
Email:
Phone Number:
Fax Number:

Executive Summary:

(Provide a half-page brief narrative descriptive summary of the disaster. What were the characteristics the disaster? How severe is the damage? What is the extent of the losses and what are the likely short-term and long-term needs? How many people were affected and how many regions, districts, or cities? Remember you are just creating a quick picture of the disaster)

Program Description:

I.Program Overview

Type of Disaster (Indicate the type of disaster affecting the population)
When did the disaster event occur?
(Indicate the date when the disaster occurred)
Beneficiary Numbers (Indicate the numbers of beneficiary targeted by your organization in this disaster)
How many people are affected and what percentage of the overall population is this number?
(Indicate the number of people that have been affected – if possible, also identify the gender, age and other demographic details of the population affected)
How many people are displaced or evacuated?
(If possible, indicate where they have gone, as well, if possible, specify the gender and age composition of those affected)
What is the physical and/or financial damage to crops and livestock?
(Indicate the amount and extent of physical and financial damage to crops and livestock)

II.Program Operations

Give a brief description of what your organization proposes to do. Attach Emergency Response Plan/Program Strategy if available. (Indicate what your organization proposes to do to respond to this emergency)
What is the proposed duration of this program
(Indicate how long you expect to be implementing an emergency response operation)
Which group of people were chosen for assistance and why? (Indicate and specify who will benefit from your response operation, and explain your selection criteria those groups)
What transport will be required and who will provide it? (Indicate what transport will you be using for the emergency)
Who will carry out the operation? (Like: Org Staff, Volunteers, Local Government)
(Indicate and specify the human resources that you have available to carry out this operation)
What is your organization’s reporting mechanisms? (Indicate your communication and reporting schedules for this emergency)
What are the organization’s requirements to carry this emergency relief operation? / a. What is the quantity of food that you are requesting from Rise Against Hunger?
b. What is the quantity of food that you plan to procure or obtain as donations from other sources?
c. What other materials are you currently fundraising for in order to respond to the current crisis?
(We do periodically have other goods, such as water filters, hygiene kits, or soap available as well. Please email to verify the availability)

III. Exit Strategy

Briefly describe your exit strategy plan

IV. Distribution Logistics

1. How is your organization planning to ship the aid?

2. What are the availability, location and condition of roads, airports, ports and railways? (Indicate the conditions of these after the emergency and not prior to the emergency)

3. What storage facilities your organization is/will be using to properly store the emergency relief supplies?

4. List the name, address, phone, email and fax number of the consignee who will clear RAH cargo through customs:

Name of Company/Organization:
Full Address:
Primary Contact Name:
Email:
Phone Number:

5. What specific documentation (licenses, exemptions, etc.) is required in your country to import food? Is a customs pre-inspection needed? Please list any restrictions the receiving country imposes on food products.

V.Supporting Documents - If Available

- Monitor & Evaluation Framework

- Budget for the Emergency Relief Operation

- Rapid Needs Assessment Checklist/Form

- Emergency Response Plan / Program Strategy

Please email completed form to Silvia Roscot, Technical Advisor for Food Security, Crisis and Resilience: or