HomeMy WebLinkAboutExhibit 14The Children's Trust
Grant Application Forms
The Trust RFP/ITN Number:
The Trust RFPIITN Title:
Proposed Project Title:
A. Agency Information
Applicant Agency Legal Name:
Federal Identification Number:
Contact Street Address: State:
City:
Telephone Number: Fax Number:
CEO/Executive Officer:
Chief Financial Officer:
Public Relations Contact:
Application Contact Person:
Contact Person E-mail:
Type of Entity (click one box):LJ
0
Corporation
Private -for -profit
Private -not -for -profit
Federal government
State government
County government
City government
Other (specify):
Licensed to do business in
Florida? (click one box)0 YES
❑O
B. Finances and Insurance
Agency Fiscal Year Begins:
Amount Requested (fills
automatically from budget):
Other/Matching Funds (fills
automatically from budget):
Total Program Value (fills
automatically from budget):
Insurance Coverages:
*Comprehensive Coverage/ ❑
General Liability 0
Workers' Compensation ❑
Automobile
'Note: If General Liability coverage amount is less than
ef $l Liabil0�it0yDinsAgency
ance pr or to contract execution
A minimum of $500,000 Comprehensive Gen
Phone:
Phone:
Phone:
Phone:
Fax:
Cover Page 1
Zip Code:
Agency does not car
Amount of Coverage Expiration Date
The Children's Trust
3rant Application Forms
Cover Page 2
C. Relationship with The Children's Trust
Has Agency ever held a contract ❑wi h he Children's Trust? YES ❑ NO (go to Cover Page 3)
If YES, List most recent contract number(s) (up to 3):
if YES, has Agency previously submitted the current version of each of the following documents?*
Financial audit 0 YES -Period of Audit: L
❑ NO
Unaudited financial
statement ❑ YES -Fiscal Period:
❑ NO
Current board of directors 0 YES
NO
*If previously submitted documents are valid and time periods current for this application,
items do not need to be resubmitted; just check YES above for each item currently on file
The Children's Trust
Grant Application Forms
Cover Page 3
D. Proposed Number to be Served Total Number of Unduplicated From age Up to age
years): (in years):
Participants to be
Served:
Estimated Numbers to be Served by Age Range (total should equal total number
t 1above):
3 years
Birth to 2 years 14_18 years
3-5 years
11-6-10 years Adult Parents/Caregivers
Estimated Numbers to be Served by Population Type (total should equal totatnumber listed above):
Children with Disabilities
At -Risk Participants
General Population
E. Service Delivery Categories and Descriptions
Sfrateaic Funding Categories (select one, and complete requested information):
�] Out -of -School Programs (refer to RFP for definitions
gi#ehancement Only
expansion) a -Round Programs
CHECK ONE: 0 Summer Only y
CHECK ALL THAT APPLY: ❑ Program Enhancement
❑ Program Expansion
❑ Promotion & Prevention (refer to RFP for definitions of approaches)eected❑ OutreachlAdvocacy
CHECK ALL THAT APPLY: ❑ Universal
❑ Resource Network (CHECK ONE program focus area below) ❑ SafetyNiolence Prevention
❑ Maternal/Infant/Child Health &Development ❑Adolescent Risk Reduction
❑ .Children with Disabilities
❑ Other (briefly specify):
❑ Service Partnership (describe specific population/neighborhood on Primary Population Worksheet)
CHECK ONE: ❑ Po ulation-based 0 Nei hborhood-based
❑ Other (specify RFP/1TN):
Will any fees be charged/collected for the pro osed services? our bored
DI YES -Briefly explain: 1 will charge parents in based on income eligibility and other criterias tnathave been developed by
❑ NO
of directores.
Does the proposed program include a health component?
❑ YES -please identify and fully describe this on the Activities Description Worksheet
❑ NO
Does program include participant transportation?
0 YES -transportation is available to/from all standard services
0 YES -transportation is provided for special services only (e.g., field trips)
❑ NO -transportation is not provided
Number of youth workers (age 16-22) proposed program will utilize:
Number of volunteers proposed program will utilize:
Expected number of volunteer hours to be contributed:
L�J