Plant Change - Awareness Mini Grant Application

Plant Change - Prevention, Reentry, Intervention Mini Grant Application
Organization Information:
Organization/Group Name:
Organization President/Director
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact Number
Alternate Number
E-mail
Your E-mail Address
Program Manager/ (if different):

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Program Manager Contact Number
Program Manager Alternate Number
Program Manager Email
example@example.com
Program Information
Program Type

Prevention Intervention Re-entry
Program Cycle Funding Request

Special Cycle Apr - Jun 2022 Cycle 1 Jul-Jan Cycle 2 Dec-Jun
Program Title
Program Location / Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
List of other partners or resources outside of your organization

Budget and Budget Narrative

Please describe exactly how funds will be used in support of program activities and outcomes. The narrative should follow the budget categories explaining what personnel costs and benefits will be paid, what funds will be used for transportation, supplies, facilities, equipment or other expenses. In addition, please explain how funding or in-kind contributions from other sources will be used; a minimum of 20% of program costs should be funded outside the grant (that's a 25% match to grant funds). As with other narratives, you can copy and paste your answer from another document.
Budget Narrative (250 words max)
Match Requirements
Each application must contain a 25% match to support the proposed program. Describe the matching resources identified to support the program. You must be able to provide the dollar value of matching resources for the program. Your match provided must have a direct relationship to the program. Please include your match in the budget form.

Eligible match may include cash contributions, donated materials or services, volunteer labor, and reductions in cost.
- Donated or volunteer labor is valued at the rate published by the Independent Sector (http://www.independentsector.org) for Virginia in the last published calendar year.
- Donated or discounted professional services will be valued at the full cost of the service provided. Professional services are servicing a person provides for paid employment that are offered at a reduced rate; the difference between what the professional normally charges and what they charge the organization may be counted as matching funds. These services must have a direct contribution to the program in order to be counted as a match.
- For reductions in cost, donated materials, and services price quotes must be obtained from multiple vendors to substantiate the value of the match.
Programs most likely to receive approval are those which plan to utilize grant funds along with other resources from their community to develop sustainable programs. Therefore, you may wish to aggressively recruit volunteer labor or contact local businesses, financial institutions, and other agencies about other possible resources in support of the program.

Sustainability and Collaboration Plan (not required but highly encouraged)

Programs most likely to receive approval are those with established partnerships and/or established relationships with other community organizations. You may wish to proactively recruit volunteer labor or contact local businesses, financial institutions, and other agencies about other possible resources in support of the program
Grant Request - Budget Worksheet

Please note, the amount requested cannot exceed $10,000

Personnel Costs

	Description (please provide detail)	Cost
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Total Personnel Costs
Automatically calculated for you.

Benefits Costs

	Description (please provide detail)	Cost
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Total Benefits Costs
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Transportation Costs

	Description (please provide detail)	Cost
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Total Transportation Costs
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Supply Costs

	Description (please provide detail)	Cost
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Total Supply Costs
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Facility Costs

	Description (please provide detail)	Cost
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Total Facility Costs
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Equipment Costs

	Description (please provide detail)	Cost
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Total Equipment Costs
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Food Costs

	Description (please provide detail)	Cost
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Total Food Costs
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Other Costs

	Description (please provide detail)	Cost
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Total Other Costs
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Total from Personnel, Benefits, Transportation, Supply, Facility, Equipment, Food, and Other Costs
This amount should NOT exceed $10,000 or applications will not be accepted.
Attach any related fliers, planning minutes, designs, event permits or photographs here

Cancel of
Attach any related fliers, planning minutes, designs, event permits or photographs here

Cancel of
Attach any related fliers, planning minutes, designs, event permits or photographs here

Cancel of
Total Amount Needed to Contribute
This is 25% of the total amount request, not exceed $2500
I certify

I certify that all information entered above is valid and true.

Plan and Timeline

Explain your action plan with estimated times for completion. It should include all activities, marketing, and recruitment. A timeline can be used for this section, sample below:

Type a question

	Time Frame	Action Item	Purpose	Responsible Party
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Partnerships should also be clearly identified. A sustainability statement should also be included in the program plan. If collaborating with another agency, please detail in what capacity.
How will participants be recruited?
Where will the program be held?
Are you planning to use a Hampton Community or Neighborhood Center? If you answer yes, please download, complete, and submit the "Facility Intent to Use Form" available on the www.hampton.gov/parks website.

Yes, we will use a Community/Neighborhood Center and will submit the appropriate form No, we will not be using a Community/Neighborhood Center
Will transportation be provided? *

Yes No
Approximately how many hours will participants spend in program activities each week? (enter a number)
For how many weeks will the program run? (enter a number)
What plan do you have to implement the program if we continue to face restrictions based on the COVID19 pandemic?

List at least FIVE measurable outcomes. (Example: 85% of participants will improve their conflict resolution skills as demonstrated through a pre and post assessment)/

	Measurable Outcome(s)
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Please share any additional information on the program, its participants, and recruitment.

Required Signatures
If awarded, the scope of work and implementation of the program are the responsibility of the organization. Progress reports must be submitted and the City of Hampton Office of Youth and Young Adult Opportunities must be identified when promoting the funded program. By signing below, we verify that this program has been discussed by a representative body of the applying group and that all information contained herein is accurate.

NOTE: Application Deadlines

Applications will be received online, in person, by mail, or by email no later than 11:59 pm on the application close date. All applications that are turned in or received after the deadline will not be considered.

Please send all information or inquiries to the following contact:

Charone Dew
Projects and Grants Coordinator
Office of Youth and Young Adult Opportunities
1 S. Mallory St. 2nd Flr, Phoebus Branch Library
Hampton VA, 23663
(757) 727-2749
charone.dew@hampton.gov
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Plant Change - Prevention, Reentry, Intervention Mini Grant Application

Organization Information:

Program Information

Budget and Budget Narrative

Match Requirements

Grant Request - Budget Worksheet

Program Narrative Instructions

Plan and Timeline

Required Signatures