FY 2024.2025 Fallbrook Regional Health District Youth Fitness Grant Application

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.

YESNO - Contact District staff.

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)

3

What is your EIN/Tax Exempt 501(c)3 designation ID#?* This field is required.Do not include the dash.

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.

YESNO - not eligible for consideration

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

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

Country

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.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

8

Financial Documents - P&L and Balance Sheet* This field is required.Most recent Fiscal year-end P&L and Balance Sheet.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

9

Financial Documents - 990* This field is required.Most recent 990

Drag and drop files here

Select files to upload

10

What year was this Organization or program started?

11

Organization’s Mission Statement* This field is required.

0/150

12

Organization History & Accomplishments* This field is required.Briefly describe your organization’s history and notable accomplishments from within the last 5 years as it relates to the provision of this program.

0/300

13

Program Description* This field is required.Please provide a short description of the program and the health benefits of the participants. Feel free to provide details about how the funds would be used to support your mission.

0/300

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.

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.

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)

Young Adults (13-17)

Adults (18-60)

Children (infants to 12)

Young Adults (13-17)

Adults (18-60)

Percent of program participants

Estimated number of participants

Percent of program participants

Estimated number of participants

Percent of program participants

Estimated number of participants

Percent of program participants

Estimated number of participants

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

Male

Non-binary

Unknown*

Female

Male

Non-binary

Unknown*

Percent of program participants

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

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

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.

0/250

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.

YESNO

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.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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.