Opportunity Connect Activity, Program, or Event Support Request Form

Opportunity Connect Activity, Program, or Event Support Request Form
The Office of Youth and Young Adult Opportunities through the Opportunity Connect program links local communities to empowering resources and services designed to mitigate the impacts of violence, drugs, or gang participation while addressing unresolved trauma and supporting returning citizens.

The goals of the program are to:

• End the cycle of insufficient resources to meet the necessities of life and sustainability
• Mitigate the cycle of trauma for individuals, families, and the community
• Stop the needless loss of life by reducing drug, gang, and gun related violence;
• Help individuals transitioning from incarceration identify support

The purpose of this document is to establish the Scope of Work for a service or resource provided through the Opportunity Connect Program.

Out of School Time Activities or Pro-Social Activities Application: Includes financial support to a charitable organization, community group or non-profits to facilitate activities that create strong relationships between neighbors and active citizens and youth in positive activities including, but not limited to, resource support, athletics, recreation, fine and performing arts, and other clubs and organizations constituted as an out-of-school activity of community event.
Please check the services/assistance desired:

Registration Stipends, or scholarships, for individuals to participate in pro-social events, programs, or activitiesIncentives for participation in mentorship programs as a participant or mentorEconomic Assistance for community events or programs or group field trips
Amounts will be informed by base rates and general practices observed by the Office of Youth and Young Adult Opportunities. Funding is considered based on available resources.
Applicant Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Media
Are you applying as an organization or individual?

OrganizationIndividual
How many people are you applying for?
If your application is approved you will be asked for documentation to support your request. Likewise, all correspondence and agreements will be generated from the information provided on the upcoming pages.

Stipend and Scholarship Request Information
Stipends and Scholarships are for persons participating in out-of-school activities to cover out-of-school activity registration fees, program cost, or supply and uniform cost. If applying for this service please include the name of the program or course, the cost per person, and the organizations contact information below.
Name of Program
Cost Per Person or by Project:
Organization Name:
Organization Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Phone Number:
Please enter a valid phone number.
Organization Email:
example@example.com

Mentorship Program Request Information
Are you applying as a participant or mentor?:

participantmentor
Mentorship Program Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mentorship Program Phone Number:
Please enter a valid phone number.
Mentorship Program Email:
example@example.com
How long is the program?:

Community Event or Field Trip Donation Request Information
The Opportunity Connect Field Trip donations provides funds for youth and young adults up to 24 years of age to give Hampton youth an opportunity to explore more of the world outside the local community. Funds may be used to cover trip related costs such as transportation, ticket fees, food, resource materials and supplies. Each grant is valued up to $3,000.00.

Community Events are generally programs, seminars, summits of small events designed to build community cohesion, empowerment and influence positive change in vulnerable communities.
Field Trip or Community Event Location:
Date of Field Trip or Community Event:

MonthDayYear
Date
Time of Field Trip or Community Event:
Field Trip or Event Description:
How many people are you applying for?:
Please include the age range of participants?:
How much funding are you requesting?:
List all planned expenses and all items you plan to purchase:
Will this event be chaperoned?:

YesNo
If yes, how many chaperones?:
Name of Main Contact for Event/Field Trip:

First NameLast Name
Main Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact Email:
example@example.com
Main Contact Phone Number:
Please enter a valid phone number.

Applicant Commitment Statement

A commitment condition will justify funding if the Office of Youth and Young Adult Opportunities enters a contract with the Applicant. The Applicant will work with the Senior Family Services Coordinator upon receiving funding.
Please include your Applicant Commitment Statement below: *

0/500
Opportunity Connect Services and Assistance Terms and Conditions
• The applicant understands the Office of Youth and Young Adult Opportunities reserves the right to request the return of any funds provided and may initiate legal action by the city to collect such funds for failure to adhere to the commitment agreement.

• However, if there are availability changes, the recipient may request an extension from the OYYAO Director, prior to 30 days from the date of application.

• The City of Hampton or any of its Departments reserves the right to cancel this proposal with no liability.

• This Service Request DOES NOT constitute a written agreement, contract, nor promise to initiate a contract between the Office of Youth and Young Adult Opportunities and the applicant, for education funding support or incentives.

• Hold Harmless/Indemnification: Should a contract be entered, it is understood and agreed that the recipient hereby assumes the entire responsibility and liability for any and all damages to persons or property caused by, resulting from, or arising out of any act or omission on the part of the applicant. The applicant agrees to indemnify and hold harmless the City of Hampton, its agents, volunteers, servants, employees, and officials from and against any and all claims or suits due to, arising out of, or in connection with (a) any and all damages, real, or alleged; (b) the violation of any law applicable to this Agreement; and (c) the performance of the work by the applicant or those for whom the applicant is legally liable. Upon written demand by the City of Hampton, the applicants shall assume and defend at the applicant’s sole expense, any and all such suits or defense claims made against the City of Hampton, its agents, volunteers, servants, employees, or officials.

• Modification: Should a contract be entered into with the applicant, there may be no modification to the contract or donation agreement, except in writing, executed by the authorized representatives for the Office of Youth and Young Adult Opportunities and the applicant.

• Non-Assignment: Should a contract or donation agreement be entered into with the applicant there will be no assignment of its rights and duties under the contract, without the prior, written consent of the Office of Youth and Young Adult Opportunities.

• All stipends or field trips SHALL NOT be made directly to the applicant but to the designated service provider to whom is a charitable business, community group or non-profit registered with the City of Hampton’s Commission of Revenue and the State Corperation Commission.

This Proposal for Services DOES NOT constitute a written agreement, contract, nor promise to initiate a contract between the Office of Youth and Young Adult Opportunities and the applicant for payments rendered for interment services.
Applicant Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Opportunity Connect Activity, Program, or Event Support Request Form

Stipend and Scholarship Request Information

Mentorship Program Request Information

Community Event or Field Trip Donation Request Information

Applicant Commitment Statement

Opportunity Connect Services and Assistance Terms and Conditions