Saint Paul-Ramsey County Public Health --Healthy Community Investment Initiative Application Form
Please complete as soon as possible, but no later than May 1, 2015
Community organization/agency name:Click here to enter text.
Federal Tax ID number(you will be required to provide your W-9 form once approved):Click here to enter text.
Address:Click here to enter text.
Contact person name(s):Click here to enter text.
Phone number:Click here to enter text.
Email:Click here to enter text.
Please tell us about your organization:Click here to enter text.
Project area of focus (check any and all that apply):
Healthy eating
Physical activity/active living
Tobacco reduction and/or cessation
Breastfeeding support
Others(please explain)Click here to enter text.
Describe the target population(s) for this project. For example: employees, breastfeeding mothers, neighborhoods, children, seniors, low-income families, culturally diverse communities, etc.
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What is the anticipated number of people who will be impacted by this project? Click here to enter text.
Why is this project needed in your organization and/or community? Please include any supporting data and community partners you may be working with.Click here to enter text.
Please describe the details of your proposed project. Add additional lines if needed and attach upon return:
Specific activities/
items requested / Estimated costs
(not to exceed $4999 for total amount) / Goals/Objectives / Timeframe
(must be completed by August 3, 2015)
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Will you have other funding sources (other than the funds applied for here) for this project? Yes No
If yes, please describe other funding source(s) and/or support that will be used for this proposed project.Click here to enter text.
How will this funding be used to create sustainable changes in your organization and the community? For example:committing to promoting employee wellness, having bike racks for employees and customers, and/or furnishing a breastfeeding room for employees and clients to use.
Click here to enter text.
Once your application is submitted and received, Saint Paul-Ramsey County Public Health staff will contact you if your proposal meets the SHIP grant guidelines and set up a meeting to discuss next steps.
Please contact Jaya Ginter at Saint Paul-Ramsey County Public Health with any questions and if a paper copy of theapplication is needed. (preferred)or call #651-266-2449
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If returning via email, send to:
If returning via mail, send to:
SHIP, 90 Plato Boulevard West, Suite 200, Saint Paul, MN 55107
If returning via fax, send to:
#651-266-2593; ATTN: SHIP
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