APDA Iowa Chapter Exercise/Wellness Community Grant Request Form

APDA Iowa Chapter Exercise/Wellness Community Grant Request Form
Community Grant Information & Addendum Packet
Organization Information
Organization Name
FEIN (Federal Employer Identification Number)
Primary Contact Name
Primary Contact Title
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email
example@example.com
Additional Contact Name
Additional Contact Title
Additional Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Contact Email
example@example.com
Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Grant Program Details
Program Name: Example: "Shenandoah Movement Training Class" / "Grimes Rock Climbing Class" / "Des Moines Cognitive Fitness"
Program Description
Program Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program End Date (if no end date, just put 12/31 of the following year)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program Location
Program Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Program Frequency
Expected Number of Participants
Lead Instructor / Facilitator Name

First NameMiddle NameLast Name
Lead Instructor / Facilitator Qualifications
Assistant Instructor / Volunteer Name

First NameMiddle NameLast Name
Assistant Instructor / Volunteer Qualifications
How will this program benefit People with Parkinson's and their care partners?
Has the instructor completed APDA training for Fitness Professionals?
If yes, please upload a copy/screenshot of the certification.

Cancelof
Program Success Measure (returning members, growing attendance, etc.)
How will the program be evaluated? (# of attendees, can do pre and post measures)
Additional Program Information
Funding Request / History
Requested Amount (typical grant amount is $25 per exercise/wellness class)
Have you received APDA funding before?
Prior APDA Funding Amount
Will there be a fee for attendees? If so, what is the cost?
Other Funding Sources Amount
Please describe other funding sources
How will the project be sustained after the grant period? (i.e. will this program continue if funding was not available?)
Please explain any related funding history or details
Grant Payment / Mailing Details
Payment Recipient / Payable To

Alternate Recipient
Payment Recipient Name
How would you like to receive payment?
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Explanation / Mailing Notes
Should be Empty:

APDA Iowa Chapter Exercise/Wellness Community Grant Request Form

Organization Information

Grant Program Details

Funding Request / History

Grant Payment / Mailing Details