Arizona Respite Network Mini Grant Application
The Arizona Caregiver Coalition (ACC) invites community-based organizations (CBOs) to apply for mini-grants ranging from $500 to $3,500 to expand or develop respite care services. This opportunity is funded through the Arizona Lifespan Respite Grant awarded to the Arizona Department of Economic Security (ADES), Division of Aging and Adult Services, by the Administration for Community Living (ACL).
Applicant Information
Name of Organization
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Website if available
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Mailing Address
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Mission of Organization
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Contact Name
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Title
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Phone Number
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Format: (000) 000-0000.
Email Address
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example@example.com
Address and name where to send award documents if different from above
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Project Proposal
Describe the program/event date and length. Is it a onetime event or ongoing If ongoing how often/long will it take place?
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What target population and geographic area does the program serve? Please note, Mini-Grant funds are to be used for only Arizona residents.
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Approximately how many family caregivers will you serve
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How will respite be provided (E.G. consumer directed with reimbursement provided onsite by staff or trained volunteers provided in caregiver home by staff or trained volunteers).
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Location of respite service
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What is the amount of respite provided (length of time)?
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Number of Hours
Is there a fixed rate for the event? If yes, please enter the fixed rate. If no, please enter N/A.
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Is there a total cap of funds provided to a caregiver? If yes, how much?
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If an event, how will you determine the number of caregivers attending the event? (E.G Registration or sign in-sheet, etc.) Enter N/A if not applicable.
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Amount Requested for Proposal - this must match the budget template ($3,500 is the max amount that can be requested).
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Please attach: Project Budget; Organization's current W9 Form; Proof of Insurance; Proof of Non-Profit Status (if applicable); 990 or audited/reviewed statement as proof of operation for at least 12 months; Any additional certifications.
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Signature for Individual Authorized to accept award and sign waiver
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