2015-2016
GO NB Para Equipment Grant Application Form
SECTION 1. Lead Applicant Information
Organization name:
Name of lead person or official making the request:
Name of president or chair of organization
Mailing Address:
Telephone number:
Email:
Fax #:
Web site:
1.b) About your organization.
Type of organization?
Provincial Sport Organization that receives Funding Model 1 support
Provincial Sport Organization - Other
If you are a Provincial Sport Organization that receives Funding Model 1 support, please skip to
section 1c), if not, please complete the remainder of this section
What is your organization’s mandate? Please describe.
Does your organization have the following? Please check all that apply.
Constitution
Incorporation
By-Laws
Member of provincial/national association
Abuse & Harassment/Screening Policy
When was your last annual general meeting (AGM)?
1.c) Para Sport Program Information
When was your para program initiated?:
How many member clubs offer para sport programming?:
Please indicate what stage of athletes are involved in your organization (check all that apply):
First Contact
Awareness
Active Start
FUNdamentals
Learn to Train
Train to Train
Train to Compete
Train to Win
Active for Life
Please indicate the approximate number of participants, instructors, officials and administrators registered
with your organization’s para program.
Male
Participants / athletes
Instructors / coaches
Officials
Volunteers
TOTAL
Female
Total
What training/certification do your leaders currently have? (i.e. Fundamental Movement Skills, NCCP
training, Learning Facilitator, and/or any Para specific training). Please explain:
SECTION 3. Budget information
3. a) Funding acknowledgement
Will you seek or did you receive other funds?
If yes, please identify other sources of funding.
Name
Yes
No
Description
Amount
TOTAL
Will there be in-kind contributions (such as: maintenance fees, storage, etc.)?
If yes, explain:
Name
Yes
Description
No
In Kind Amount
TOTAL
3. b) Equipment Budget
All applicants are required to generate 25% of the adaptive equipment cost. Please include this portion in the
revenues section. Applicant is also required to submit a minimum of 1 formal equipment quote.
Estimated Revenues
Amount
Estimated Expenses
Amount
Items
Items
TOTAL
Total Amount Requested:
TOTAL
Section 4. Maintenance, Storage and Transportation Plan
As a requirement of the application, please provide detailed maintenance and storage plan for the acquired
adaptive equipment. Attach appendix if additional space required.
Section 5. Completion of Application
5. a) Accountability Declaration of Partners
I, the undersigned, am authorized by my organization to forward this application. The information presented
in this application is, to the best of our knowledge, true and correct.
Furthermore, in the event that our application is successful, we agree to:
1. Receive and account for all project funds, through the Lead Organization.
2. Participate in evaluation / monitoring activities related to the project.
3. Provide proof of insurance coverage for the program.
4. Ensure project is implemented and that all obligations for reporting are met.
5. Ensure that a final activity report is submitted within 4 months of the grant being received, or no later
than April 30th.
Signature of Applicant:
Date:
5. b) Direct Deposit
Are you set-up for Direct Deposit?
Yes
No
If no, please complete the Direct Deposit available through the Department’s regional consultants:
http://www2.gnb.ca/content/dam/gnb/Departments/thc-tpc/pdf/ActiveCommunitiesCommunautesActives/ActiveCommunitiesConsultants.pdf
or
through
your
Provincial/Multi
Sport
Organization’s consultant.
5. c) Applicant’s Checklist
Minimum of 1 formal equipment quote
Proof of Insurance
Direct Deposit Application Form, if applicable
Application form completed
Have you read the Funding Grant Guidelines
Read through and understand the Accountability Declaration of Partners
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
n/a
n/a
n/a
n/a
n/a
Please submit completed applications to your Regional
(http://www2.gnb.ca/content/dam/gnb/Departments/thc-tpc/pdf/ActiveCommunities
CommunautesActives/ActiveCommunitiesConsultants.pdf), Provincial Consultant or directly to the Go
NB coordinator: Ransford Lockhart by email at Ransford.lockhart@gnb.ca; fax to (506)453-6548 or mail
to: Centennial Building, P. O. Box 6000, Fredericton, NB, E3B 5H1