Access4All 'rant Application orm · Please read carefully. I, the Applicant understand and confirm...
Transcript of Access4All 'rant Application orm · Please read carefully. I, the Applicant understand and confirm...
Access4All Grant Application Form
Please note that this copy of the Access4All grant application form is for reference purposes
only. Please submit your online application at www.rickhansen.fluidreview.com. Only grant
application forms submitted online will be accepted.
SECTION I: BARRIER BUSTER PROJECT
Name of your Barrier Buster Project:
SECTION II: ORGANIZATION & CONTACT INFORMATION
A. Organization Contact Information The Recipient must be a Qualified Donee as defined by the Income Tax Act of Canada to be eligible
for the Barrier Buster Grant. If you are unsure, please see our FAQ for more information.
Organization Name
Is your organization a “Qualified Donee” as defined in the Income
Tax Act (Canada)? Yes
No
CRA Business Number
Street Address
City
Province/Territory Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and
Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Country
Postal Code
Organization Website
B. Mission & Activities
What is the mission and purpose of your organization? What are its main
activities? (max 150 words)
C. Social Media
Provide information on all social media channels that your organization uses, if
any. Twitter Handle:
Facebook Page:
Instagram Profile:
YouTube Channel:
LinkedIn Page:
Other:
D. Applicant Information & Authorization
Complete contact details of the Applicant Full Name
Job Title:
Phone Number:
Alternative Phone Number:
Contact Email:
Preferred Language of Correspondence
English
French
Authorization of Applicant Please read carefully.
I, the Applicant understand and confirm that the approval of this application by
Rick Hansen Foundation (hereinafter “RHF”) and the award of a grant by RHF to
the Recipient will create a binding grant agreement between the Recipient and
RHF and I represent and warrant that I am duly authorized by the Recipient to
submit this application on behalf of the Recipient and to legally bind the
Recipient to such grant agreement. Further, if the Recipient is an
unincorporated association I represent and warrant that I am duly authorized by
the members of the Recipient to submit this application on their behalf and to
legally bind such members personally, jointly and severally to such grant
agreement.
I Agree
Name
Job Title
SECTION III: INFRASTRUCTURE IMPROVEMENT
A. Location
Where will the Infrastructure Improvement take place? Location Name
Street Address
City
Province/Territory Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Type of premise Select type of premise School
Park / Playground
Community Centre
Recreation Centre
Arts & Cultural Venue
Place of Worship
Other (please specify):
Other (please specify)
B. Timeline
Infrastructure Improvement proposed start date ____/__/__ (YYYY/MM/DD)
Infrastructure Improvement proposed end date End date must be before December 31, 2017 to be eligible.
____/__/__ (YYYY/MM/DD)
Are the start and end dates for your Infrastructure Improvement fixed or
flexible? Fixed/Flexible Fixed: The Infrastructure Improvement is only possible
between the start and end dates provided.
Flexible: The start and/or end dates of the
Infrastructure Improvement date is flexible.
Please explain how your start and
end dates are flexible.
C. Impact & Innovation
Describe the Infrastructure Improvement you propose to make to your
premises. Include how you have consulted people with disabilities (mobility,
vision, hearing challenges). (max 150 words)
Describe how the Infrastructure Improvement will make a difference for people
with disabilities. (max 150 words)
Describe how many people the Infrastructure Improvement will impact. (max
150 words)
Describe how the Infrastructure Improvement fosters innovation – if applicable
(creative, effective approach to accessibility solutions) and is sustainable. (max
150 words)
D. Partnerships & Engagement
Partnerships Will your organization be working with other organizations (e.g.,
community groups, people with disabilities, businesses, local governments,
and/or others) to deliver the Infrastructure Improvement?
Yes
No
If yes, please name the collaborating organizations and explain their roles.
Volunteers Will volunteers be involved to deliver the Infrastructure Improvement? Yes
No
How many volunteers do you anticipate participating, and in what
capacity?
How many volunteer hours do you expect to be expended?
Youth Involvement Will youth be involved to deliver the Infrastructure Improvement? Yes
No
If yes, please describe how youth will be involved.
Community Involvement How many community members do you expect to participate in the
Infrastructure Improvement?
Please provide any additional information on how the larger community
will be involved.
E. Expertise
Describe the skills, experience and/or expertise of your organization (and/or
collaborating partners) to implement the Infrastructure Improvement (max 150
words)
SECTION IV: AWARENESS EVENT This section seeks information about your Barrier Buster Project’s Awareness Event that will
celebrate the completion of the Infrastructure Improvement to your premises and raise awareness
within the community.
A. Location
Where will the Awareness Event take place? Same as Infrastructure Improvement site
Location Name
Street Address
City
Province/Territory
B. Timeline
Awareness Event proposed date Event must take place on or before January 31, 2018
____/__/__ (YYYY/MM/DD)
C. Awareness Event Reach and Impact
Describe the proposed Awareness Event, how it will showcase the Infrastructure
Improvement to the community and stakeholders, and the number of people
reached. (max 150 words)
Describe how your organization will generate media and public interest before,
during and after the Awareness Event (max 150 words)
Describe how your organization will engage government officials and other
notable guests at the Awareness Event (max 150 words)
D. Partnerships & Engagement
Partnerships Will your organization be working with other organizations (e.g.,
community groups, people with disabilities, businesses, local governments,
and/or others) to deliver the Awareness Event?
Yes
No
If yes, please name the collaborating organizations and explain their roles.
Volunteers Will volunteers by involved to deliver the Awareness Event? Yes
No
How many volunteers do you anticipate participating, and in what
capacity?
How many volunteer hours do you expect to be spent?
Youth Involvement Will youth be involved to deliver the Awareness Event? Yes
No
If yes, please describe how youth will be involved.
Community Involvement How many community members in total do you expect to participate in the
Awareness Event?
Please provide any additional information on community involvement, if
any
Official-Language Minority Community Involvement An Official Language Minority Community consists of Francophones who reside outside of Quebec,
or English-speaking residents of Quebec.
Will the Official-Language Minority Community be invited to attend the
Awareness Event? Yes
No
Will artists or performers of the Official-Language Minority Community be
invited to perform at the Awareness Event? Yes
No
Please describe how the Official-Language Minority Community will be
involved in the Awareness Event.
E. Expertise
Describe the skills, experience and/or expertise of your organization (and/or
collaborating partners) to deliver the Awareness Celebration Event. (max 150
words)
SECTION V: BUDGET & FUNDING SOURCES Please be sure to upload your budget. You can use the sample form provided.
Estimated Total Project Cost What is the budgeted cost of the Barrier Buster project? Inclusive of all taxes.
Infrastructure Improvement cost:
Awareness Event cost:
Total
Requested Barrier Buster grant amount Enter the Barrier Buster Grant requested amount.
Infrastructure Improvement (up to $20,000):
Awareness Event (up to $10,000):
TERMS & CONDITIONS
By submitting this application form, I acknowledge on the behalf of the Recipient, I agree to
the Terms and Conditions and have read the Privacy Policy of the Access4All Canada 150
Signature Initiative.
I consent to be contacted with further information about Rick Hansen Foundation.