Heartland Forward and LULAC Grant Request Form

Name of Organization/Council*

Name of Point of Contact*

Phone Number*

Email Address*

Mailing Address*

City *

State *

Zip*

What type of events or activities will you be hosting? (ex. canvassing, tabling, etc.)*

What is your date event/activity #1 ? (please note applications will only be accepted for events/activities submitted 4 weeks in advance or more)*

MonthDayYear

What is your date event/activity #2 ? (please note applications will only be accepted for events/activities submitted 4 weeks in advance or more)*

MonthDayYear

Why is it important for your council to participate in this initiative? Please discuss the need in your community. *

Does your council have any prior experience with carrying out a program similar to this?*

YesNo

If you selected yes, please describe the experience here:

How many people are you expecting to attend?*

How will you ensure that you reach the minimum amount of people that we are asking for?*

Do you have a designated coordinator that can work with LULAC and Heartland Forward staff to plan, coordinate, and lead the program onsite?*

YesNo

If yes, please put their name, number and email below.

What partnerships locally can you activate to ensure the success of your program? Please describe any organizations or entities that you can work with to reach eligible households in your community.*

Describe the plan you have in place to use this partnership.*

Describe your LULAC Council's capacity to host the event or activity while complying with social distancing guidelines and CDC health guidelines.*

Do you have the equipment necessary to be able to enroll the individuals up for ACP? Internet access, tablets, cell phone, laptop*

YesNo

If yes, please describe. If no, please tell us what you would be needing. *

Racial and Ethnic: Please provide the percentage of the community by racial and ethnic identity in the community. Total must equal 100%. If you do not track ethnic and cultural data, please make an educated estimate and do not leave any area blank. Use a zero entry where appropriate:*

Income Level: Please provide the percentage of low-income individuals served by the project. If this population is not served by program, insert N/A. *

Are you willing to commit to a training covering eligibility and execution of enrolling the Latino Community in ACP?

YesNo

Awardee Fiscal Information: If your site is selected, the fiscal agent named below will be responsible for administering monies sent on behalf of Heartland and LULAC as well as providing any fiscal reporting.

Checks are made payable to (must be an organization)

Checks are to be mailed to this address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any additional questions or concerns that we need to address?*

By submitting this application I commit to providing all reports in a timely manner and participating in check-ins if my council is chosen.*

YesNo

Full Name*

Signature

Date*

MonthDayYear