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Youth Fitness Grant Application
For Fiscal Year 2024-2025
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Language
English (US)
Spanish (Latin America)
1
Tax Exempt Status
*
This field is required.
1. The agency must be an incorporated nonprofit organization with a tax-exempt status under California state law and Section 501(c)(3) of the Internal Revenue Code, or, be a public/governmental agency, program or institution. Newly established agencies must: a. Demonstrate, through written agreement with a 501(c)(3) qualified agency that, for the one-year period of the CHC, they will fall under the auspices of that qualified agency. The agency providing the umbrella status must meet the District requirement of being an established provider of healthcare related preventive or intervention services to the public in the District community. b. Secure 501(c)(3) status within the CHC funded year. If they fail to secure 501(c)(3) status, they will be ineligible for subsequent application for Fallbrook Regional Health District funding until such time as proof of 501(c)(3) status has been attained and presented.
YES
NO - Contact District staff.
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2
Organization Name
*
This field is required.
Please provide the legal name of the organization, as it appears on your 990. If you have a different DBA or nickname please add that in the box adjacent to the legal name.
Legal Name
DBA (if Applicable)
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3
What is your EIN/Tax Exempt 501(c)3 designation ID#?
*
This field is required.
Do not include the dash.
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4
Will you be able to document that 100% of the grant program recipients live within the communities of Fallbrook, Rainbow, Bonsall or De Luz?
*
This field is required.
YES
NO - not eligible for consideration
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5
Contact Information
*
This field is required.
Please add the contact information for the person responsible for the submission and monitoring of this grant application.
Contact Name
Title
Primary Contact Phone
Email Address
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6
Organization Mailing Address
*
This field is required.
This address will be used for all mailing purposes.
Mailing Address
Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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7
Board of Directors
*
This field is required.
Please upload a list of your Board of Directors: include Full Name - First, Last, Board Position, Professional Affiliation/Industry and contact email address.
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: 10.6MB
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8
Financial Documents - P&L and Balance Sheet
*
This field is required.
Most recent Fiscal year-end P&L and Balance Sheet.
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Max. file size
: 10.6MB
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9
Financial Documents - 990
*
This field is required.
Most recent 990
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10
Organization’s Mission Statement
*
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11
Organization History & Accomplishments
*
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Briefly describe your organization’s history and notable accomplishments from within the last 5 years as it relates to the provision of this program.
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12
What year was this Organization or program started?
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13
Brief Program Description
*
This field is required.
Please provide a short description of the program. This is the "elevator speech version", you will have the opportunity to fully explain the program later.
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14
Funding Amount Being Requested
*
This field is required.
Please fill in the total amount of funding being requested from FRHD through this 2024.2025 Grant cycle. Please note that the award maximum is $5,000.
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15
Projected number of residents that will directly benefit (participant/client) from this program.
*
This field is required.
The number of residents that receive the service or who are enrolled in your program.
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16
Target Population - Age
*
This field is required.
List the percentages of your program participants’ ages. Percentages must add up to 100%
Percent of program participants
Estimated number of participants
Children (infants to 12)
Row 0, Column 0
Row 0, Column 1
Young Adults (13-17)
Row 1, Column 0
Row 1, Column 1
Adults (18-60)
Row 2, Column 0
Row 2, Column 1
Row 3, Column 0
Row 3, Column 1
Children (infants to 12)
Young Adults (13-17)
Adults (18-60)
Percent of program participants
Row 0, Column 0
Estimated number of participants
Row 0, Column 1
Percent of program participants
Row 1, Column 0
Estimated number of participants
Row 1, Column 1
Percent of program participants
Row 2, Column 0
Estimated number of participants
Row 2, Column 1
Percent of program participants
Row 3, Column 0
Estimated number of participants
Row 3, Column 1
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17
Target Population - Gender
*
This field is required.
List the percentages of your program participants’ gender identification. Percentages must add up to 100%
Percent of program participants
Female
Row 0, Column 0
Male
Row 1, Column 0
Non-binary
Row 2, Column 0
Unknown*
Row 3, Column 0
Female
Male
Non-binary
Unknown*
Percent of program participants
Row 0, Column 0
Percent of program participants
Row 1, Column 0
Percent of program participants
Row 2, Column 0
Percent of program participants
Row 3, Column 0
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18
What language(s) can this program accommodate:
*
This field is required.
Where most or the at least half of the program can be provided in the participant's primary language.
English
Spanish
Tagalog
Chinese (Mandarin/Cantonese)
Other
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19
Anticipated Acknowledgment
*
This field is required.
Please select the methods by which the Organization will acknowledge the District's investment of funding.
Social Media Postings
Signage at Service Sites
Print Materials to Service Recipients
Website Display
Other
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20
Anticipated Acknowledgment
*
This field is required.
Please explain how the District's name or logo will be promoted. If social media is selected, please identify which platforms your organization utilizes.
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21
Agreement - Selecting Yes certifies that the organization will do its best to solicit and communicate to the District the results from the participant's Impact Survey.
YES
NO
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22
Program Budget
*
This field is required.
Please upload the Program Budget & Narrative file. Use the District provided spreadsheet which can be found here https://www.fallbrookhealth.org/community-health-contract-grants.
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23
Terms and Conditions
*
This field is required.
Checking this box certifies that all information presented in, or attached to this application is complete and accurate.
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FY 2024.2025 Fallbrook Regional Health District Youth Fitness Grant Application
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