Community Impact Challenge Application Form 2024-2025

Community Impact Challenge

2024-2025 Application Form
In an effort to support community engagement and service in underserved communities, APTA North Carolina’s Diversity, Equity, and Inclusion Committee launched the Community Impact Challenge (CIC) which will award 2 programs (all PT and PTA programs are eligible) monetary awards up to $1,500 each (award amount is dependent on the budget submitted with the application), to assist with the implementation of a project/activity that addresses a community need. In addition to monetary awards to support the project/activity, award winners (1 per project) will be awarded registration for the APTA North Carolina Annual Conference and Student Conclave. If you would like to be considered for an award, please complete this form by 11:59 pm on December 10, 2024. Applicants will be notified of their application’s status in January 2025. If selected for funding, applicants must commit to implementing the proposed project/activity by September 2025 AND present an overview of the project at the APTA North Carolina Annual Conference in October 2025 (date TBD).
Name

First NameLast Name
Email
example@example.com
PT/PTA Program
Program Chair/Director
Are You an APTA North Carolina Member?
Additional Collaborators
*PT/PTA Collaborations are highly encouraged
PT/PTA Program
Program Chair/Director
Please provide an overview of your CIC proposal including the community need, goal, timeline, and the anticipated outcome(s): (750 words max)
Total Estimated Budget (attach itemized budget) *Awarded funding for your project may be used for direct costs or other reasonably supported expenses related to the costs. The funds CANNOT be used for overhead or indirect costs. A successful proposal will thoroughly address each anticipated cost/expenditure with a clear justification and include an itemized budget to support projected expenditures.
Attach itemized budget:

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Will you be needing funding outside of this award to complete your project?
If yes, what is your additional source of funding?
Note: Please ensure that you work in collaboration with your PT/PTA Program leaders, colleagues and community partners (if applicable) to develop this project.

By signing this form, you confirm that all the information is true and correct, to the best of your knowledge. If selected as a winner, you agree to the appropriate use of funding and implementation of the project/activity within the designated timeframe and sharing an overview of the project/activity in the form of a presentation at an APTA North Carolina event.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: