Healthy Community Grant Application Form

Application #8907084: Last edited on

Contact

Principal Applicant

Co-Applicant

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Principle Applicant

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Co-Applicant

Organization







You may be asked to provide audited year-end FINANCIAL STATEMENTS.

Proposal



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Budget & Fundraising


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50%

Please upload your BUDGET, which must include:

  • All expenses as separate line items (total must add up to the amount requested)
  • All revenues and any funds raised to date (if applicable)
  • Quotes for equipment over $3,000

Summary of Confirmed Funds Raised to Date

What other fundraising is being done to secure the funds needed for this initiative? State all other sources of funding that you have approached, the amount requested, the status of your request and date the request was made. Where funding has been confirmed, we may require written confirmation from source or copy of cheque (we’ll contact you later for this information).


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23-Nov-2016

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A. Source

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23-Nov-2016

B. Source

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C. Source

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Summary of Other Fundraising Activities in Support of This Initiative


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A. Source

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B. Source

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C. Source

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Acknowledgement

By our signatures below, we hereby agree to abide by all decisions of the Healthy Community Grants Committee and Peace Arch Hospital & Community Health Foundation (PAHCHF), including but not limited to the Application Guidelines and Conditions of this application. We agree that all funding decisions are final and no discussion will be entered into following the decision. All application material becomes the property of PAHCHF for its use or release of same material for any purpose including publicity and funding agencies shared databases.

By typing my full name below, I hereby agree to abide by all decisions of PAHCHF, including but not limited to the Application Guidelines and Application Conditions above.

I agree that all funding decisions are final and no discussion will be entered into following decision. All application material becomes the property of PAHCHF for its use or release of same material for any purpose including publicity.

All personal information gathered by PAHCHF regarding the applicant will held in the strictest confidence and treated as such under current privacy legislation. Personal information will only be shared with the Healthy Community Grants Committee and Foundation’s Board of Directors.

Approvals

By inserting his/her full name below, you confirm that the following persons have granted approval for this proposal.

For ORGANIZATIONS / AGENCIES Only

For PAH / FHA Only

For FHA Only