HomeMy WebLinkAboutAPPLICATION FORMApplication Form (to be formatted into a fillable PDF file)
PROPOSAL INFORMATION
Total Request:
APPLICANT INFORMATION
Name of Applicant Organization:
Mailing Address:
City, State, Zip:
Phone:
Fax:
Email Address:
Website:
Federal Tax Identification Number:
Type of Organization:
Government
Non-Profit
For-Profit
Other (please specify):
PROJECT CONTACTS
Name of Organization Director:
Phone:
Email:
Project Contact Name:
Title:
Phone:
Email Address:
Fiscal Contact Name:
Phone:
Email Address:
Name and Title of Authorized Representative:
Acceptance of this application may be subject to subsequent compliance reviews, including a review
of the latest audit of financial statement. Preparation of an application does not guarantee that
applicants will receive funds. By signing this grant application form the undersigned certifies that all
information is accurate to the best of his/her knowledge.
__________________________________ ____________
Signature of Authorized Representative Date
PROPOSAL DETAILS
1. Applicant Profile and Qualifications: Tell us briefly about your organization including
your mission, your goals, any history, and years of experience providing services for
individuals with developmental disabilities, experience managing public funds, and
anything else that describes the organization’s qualifications. (max. 250 words)
2. Project Description Summary: Indicate how the proposed activities meet the
requirements of the information and education funds (see Section 1 of the RFP) and
provide a brief summary and general description of the activities being proposed.
Include how many people will be served or reached. Indicate all areas that apply. (max.
250 words each area)
Community Information and Education:
Training
i. Staff training:
ii. Board Training:
Other Activities
i. Infrastructure projects:
ii. Startup projects:
iii. Partnership projects:
3. Partnerships: List your key community partnerships for the proposed project and
describe what their role will be. (max. 250 words)
4. Gaps and Duplication in Services: Describe how your proposed project fills a gap in
services that wouldn’t otherwise exist in Kittitas County. Include a description of how
the project is or isn’t a duplication of current services. (max. 250 words)
5. Funding Utilization: Describe how the funds will be used to support the proposed
activities. For example, will the funds be used for staff time, supplies, consultants,
travel, training, direct customer services, etc.? (max. 250 words)
6. Partial Funding: If this project were to receive only partial funding from this source,
how would the proposal be impacted? How would the proposal be adjusted for less
than the requested amount of funds? (max. 250 words)
7. Goals & Objectives: Use the Goals and Objectives Form below to fill in the following
table with your project’s goals, measures, strategies, and objectives. See the examples
below for guidance and use as many forms as necessary.
Example #1:
GOAL: Increase number of people enrolled in health insurance by 25% by December 31, 2017.
Measures (How will you know you are making progress toward your goal?) Data Source
Number of new enrollees in health insurance Internal tracking
sheet
Strategy #1
(What will you do to achieve your goal?)
Create promotional materials to distribute to local partners
advertising health insurance enrollment assistance.
Measurable Objectives:
Promote the service with at least 5 community
partners each quarter through December 2017.
Distribute at least 100 flyers around the community by
December 2017.
Strategy #2
(What will you do to achieve your goal?)
Offer health insurance enrollment assistance at local
community events.
Measurable Objectives:
Attend at least 2 community events per quarter in both
Upper Kittitas County and Lower Kittitas County
through December 2017.
Strategy #3
(What will you do to achieve your goal?)
Offer health insurance enrollment assistance appointments in
the office.
Measurable Objectives:
Schedule at least 40 hours per month of open walk-in
assistance through December 2017.
Ensure staff availability for at least 25 scheduled
appointments each month through December 2017.
Example #2:
GOAL: Increase the number of trail systems available to the general public within the City of Ellensburg from 5
to 7 by December 2019.
Measures (How will you know you are making progress toward your goal?) Data Source
Number of trail systems open to the public and clearly labeled Trails report
Strategy #1
(What will you do to achieve your goal?)
Establish public-private partnerships for funding trail
construction and maintenance.
Measurable Objectives:
Create tailored presentation about project by March
2017.
Meet with at least 2 potential partners each quarter
through June 2018.
Establish at least 2 primary public-private partnerships
for trails by December 2018.
Strategy #2
(What will you do to achieve your goal?) Identify sites for new trail systems.
Measurable Objectives:
Conduct site visits with partners of potential new sites
by March 2018.
Identify pros and cons of potential new sites by June
2018.
Solidify 2 new trail sites by December 2018.
Strategy #3
(What will you do to achieve your goal?) Build new trail systems.
Measurable Objectives:
Create plans for construction of new trail systems by
March 2019.
Two new trail systems will be built by December 2019.
GOALS AND OBJECTIVES FORM
Fill out white sections only.
GOAL:
Measures (How will you know you are making progress toward your goal?) Data Source
Strategy #1:
(What will you do to achieve your goal?)
Measurable Objectives:
Strategy #2:
(What will you do to achieve your goal?)
Measurable Objectives:
Strategy #3:
(What will you do to achieve your goal?)
Measurable Objectives:
Strategy #4:
(What will you do to achieve your goal?)
Measurable Objectives:
*Use copies of the same form if you have more than 4 strategies for the same goal*