Applicant Name:

Applicant Mailing Address:

Applicant Phone Number:

Applicant Email Address:

Name of Program Director:

Program Director’s Mailing Address:

Program Director’s Email Address:

Project title and description of proposed project that serves both adults and children in narrative format (less than 200 words)

Project Objectives and Goals

Project Budget (itemized) and include whether you have submitted or received any other sponsorships or grant monies.

Describe your target population and community partners/sponsors.

Include a proposed timeline to complete your project.

List potential barriers to completing your project or barriers in your Community.

How do you plan to overcome these barriers?

How do you plan to sustain and implement your project?

How do you plan to assess the progress and achievement of your project?