The Corporation of the
City Of North Vancouver
LOWER LONSDALE LEGACY FUND
APPLICATION FORM
SUBMISSION DEADLINE: 5:00 pm
☐ March 31, 2014
☐ October 15, 2014
This application must be typed. Please use the space provided for your responses.
Attachments, faxes, handwritten, and/or late applications will NOT be considered.
APPLICANT INFORMATION:
Organization Name: Click here to enter text.
Address: Click here to enter text.
Telephone: Click here to enter text.
City: Click here to enter text.
Fax: Click here to enter text.
Project Contact Person: Click here to enter text.
P. Code: Click here to enter text.
E-mail: Click here to enter text.
Position: Click here to enter text.
Your Organization’s BC Society No.: Click here to enter text.
Your Organization’s Charitable Registration No.: Click here to enter text.
Brief History and mandate/purpose of the organization delivering this project:
Click here to enter text.
APPLICATION SUMMARY:
Project Title: Click here to enter text.
Project Description (Please provide a one sentence summary of the project):
Click here to enter text.
Project Timespan From: Click here to enter text. To: Click here to enter text.
Click here to enter text. % of total participants that will be Lower Lonsdale residents.
Click here to enter text. # of total participants that will be Lower Lonsdale residents.
Amount requested $ Click here to enter text.
Total project budget: $ Click here to enter text.
Goal (Overall purpose):
Click here to enter text.
Outcomes - What will be achieved through this project? Statements should be specific, measureable and attainable
within the project timeline.
1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
4. Click here to enter text.
5. Click here to enter text.
Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969
PROJECT INFORMATION:
What are the proposed activities and corresponding timeline? Projects are to be completed by September 2013.
Activity Plan (Specific action steps to meet desired outcomes).
Corresponding Timeline
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
Click here to enter text.
Click here to enter a date.
ADDITIONAL KEY FACTORS THAT WILL FORM THE BASIS OF REVIEW AND APPROVAL:
1 COMMUNITY DRIVEN: Identify the population(s) to be served, how they will benefit from the project, and how
they were involved in project planning, implementation and evaluation.
Click here to enter text.
2 VOLUNTEERS: Describe how you will promote, encourage and facilitate the involvement of volunteers. If known,
include the number of volunteers to this project.
Click here to enter text.
3 COLLABORATION/PARTNERSHIPS: Identify and describe the extent to which collaborating agencies,
community groups, and individuals are supporting or participating in the project (include contact names and telephone
numbers).
Click here to enter text.
Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969
4 SENSE OF COMMUNITY: Describe how the project will contribute to a sense of the Lower Lonsdale
community.
Click here to enter text.
5 COMMUNITY NEED: Describe how this project meets an identified community need recommended for action in
the Lower Lonsdale Social Development Strategy Report.
Click here to enter text.
Is this project a duplication of an existing project?
☐ YES
☐ NO
6 INCLUSIVE: List the strategies you will implement to ensure that the project is inclusive and accessible (e.g.
services are culturally appropriate, facilities are wheelchair accessible, materials are translated, etc.)
Click here to enter text.
7 EFFECTIVE EVALUATION: An evaluation report from funded projects is due within two months of project
completion. The evaluation report should include information on the following:








Goals achieved and factors influencing outcomes;
Any major changes to the project from the original application;
Completion of the proposed Action Plan and corresponding timelines
Evidence of community impact;
Attendance figures;
Demographics and origin of participants (if available);
A final accounting of revenues and expenses compared with the original budget; and
How the City’s contribution was recognized.
Repeat applications will not be considered without an evaluation of the previous project.
PROJECT BUDGET – Itemize all the expenses and all sources of revenue, including your agency's and
other "in-kind" contributions.
Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969
Expenditures:
Revenue:
Salaries/benefits
$
Contract Fees
$
Honoraria
$
Rent/ Utilities/
Phone
Printing/ copying
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Travel
Request from
$
LL Legacy Fund
(use this amount to
complete details in
Section below)
Your Organization’s
$
Cash
contributions
$
In-Kind
List Additional Revenue Sources (specify):
Confirmed?
Yes/No
Contact & Ph #
Others (specify)
Total Expenditures
Total Revenue
(including request from
$0
.
$0
LL Legacy Fund)
Note: The Budget must balance. Expenditures must be the same amount as the
Revenue.
HOW DO YOU ANTICIPATE YOUR LOWER LONSDALE LEGACY FUND GRANT $’S TO BE EXPENSED?
Itemize the expense type and the amount. (Expense types could include: Salaries/benefits, Contract Fees,
Honoraria, Rent/utilities/phone, Printing/copying, Travel)
Expense Type
Amount
Click here to enter text.
$
Click here to enter text.
$
Click here to enter text.
$
Click here to enter text.
$
Click here to enter text.
$
Total (equals grant requested from LLLF)
$0
APPLICANT’S SIGNING AUTHORITY:
Signature of President/Executive Director/Senior Staff Person:
Signature of Board Chair/President:
Name
Name
Date: .
Date
MAIL, HAND-DELIVER, SCAN / EMAIL OR COURIER YOUR COMPLETED APPLICATION TO:
City of North Vancouver, Community Development Department
141 West 14th Street, North Vancouver, BC V7M 1H9
Attention: Paul Penner, Community Planner or Edytha Barker, Committee Clerk
Please remember your application should be typed, not to exceed these 4 pages, has no attachments, not to be faxed,
and delivered to the City of North Vancouver Community Development Department on or before the deadline date at
5:00pm. Late applications will not be accepted.
Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969
Download

Applicant Information - City of North Vancouver