FOR OFFICE USE ONLY
Date & Time Received:
General Information
Name of Organization or Group:
Contact Person:
Telephone Number:
Name of supervisor, pastor, or director
of organization, church or group
Name:
Telephone Number:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Amount Requested:
Estimated Number of Individuals to be Served:
Ages of Individuals to be
Served:
Address:
From the following list, please
indicate the type of group or
organization you represent:
Student Group
School
Non-profit Organization
Community Group
Service Club
School Club
Faith-based Group
Government Agency
College/University
Other (please describe):
Please check at least one of the four priority areas you are targeting:
Reduce marijuana use among youth 12-20 years old.
Reduce AOD use among non-traditional students (ex. alternative schools).
Reduce painkiller use among youth 12-20 years old.
Reduce alcohol use by youth 12-20 years old.
Name of Project:
Give a brief description of the project (500 word max). (Please list members of Youth involved in your Project)
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MINI-GRANT APPLICATION NARRATIVE (DO NOT EXCEED 5 PAGES)
Question 1. (a)Please describe your project and how it will benefit the group, community you represent including
how youth have and will be involved in the planning and implementation of your proposed project
(b)Describe the demographics (age, gender, and race) of individuals who will be impacted by the project.
Question 2. (a)Please describe how your project will address at least one of the six priority areas.
(b)How does your project support alcohol and other drugs (AOD) prevention efforts in Fresno County?
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3. Please describe your group or organization as well as any other relevant community members or organizations that are
involved in this project. Describe roles and responsibilities of staff assigned to this project
4. Please state the purpose and goals of the project. How will you know if the project has been successful? Please identify
at least one result you hope to see.
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5. Describe how you will measure your success in addressing the problem(s) described in question 2. (Changes in
behavior, attitudes, knowledge, or skills measured through pre-post-surveys, related statistics, etc.)
6. Describe your action plan for gathering data from your project to provide the CHC an accurate summary of service
report.
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BUDGET
Please specify how you intend to use the mini-grant program funds. List estimated costs for carrying out the activities.
Identify each item, provide a budget narrative, and list budget amount. See budget and invoice sample on page 6 and 7.
Signature of Group/Organization Representative:
Date:
Applications will not be accepted via fax. Return completed mini-grant application by mail or hand-delivered to:
California Health Collaborative
SAP Mini-Grants Program
5
1680 West Shaw Avenue
Fresno, CA 93711
SAMPLE BUDGET
ITEM
EXPLANATION
AMOUNT
Travel
To cover travel expenses related to
project activities.
$ 300.00
Training
Costs associated with staff and
volunteer training in areas relevant to
the approved activities.
$ 2,500.00
Incentives
For purchase of appropriate incentive
items that encourage and reward
participation.
$ 800.00
Miscellaneous
To cover cost of unanticipated expenses
related to the project.
$ 400.00
Food
For purchase of Pizza for participants.
$ 200.00
Staff Time
Costs associated with 5 staff at 16 hours
each x $15. Responsibilities include
volunteer trainings and development in
areas relevant to the project related
activities. (Be specific: list number of
hours budgeted per staff person and
their responsibilities).
$ 1,200.00
TOTAL
$ 5,400.00
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SAMPLE INVOICE
Jane Doe
1680 West Shaw Avenue
Fresno, CA 93711
Phone: (559) 123-4567
INVOICE #3
DATE: JULY 31, 2017
TO:
California Health Collaborative
SAP Mini-Grants Program
1680 West Shaw Avenue
Fresno, CA 93711
(559) 221-6315
FOR:
PEERx Program
DESCRIPTION
AMOUNT
6/15/2012 Purchase of 20 Me & Ed’s pizza’s
$ 200.00
6/24/2012 Purchase of an Apple iPod Touch
$ 500.00
6/1-60/29/2012 Staff time: 2 at $15 x 4 hours
$ 120.00
TOTAL
$ 820.00
Make all checks payable to Jane Doe.
Payment is due within 30 days.
If you have any questions concerning this invoice, contact Jane Doe at (559) 123-4567 or by email at [email protected].
Thank you for your business!
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SAMPLE TIMELINE
FREAKS
(Finding Responsible and Entertaining Activities on KampuS)
Timeline of Activities
Primary Intervention 1: High School-level After-School FREAKS Program
Consultant Activities
1. Coordinate with Washington Unified School District staff to
develop an after-school FREAKS program designed to reduce
substance use among students.
Deliverables/Tracking
Measures
FREAKS program
initiation
Timeline
1/30/2013
2. Conduct health-risk behavior surveillance with participating
students to determine program effectiveness. A modified version
of the CDC-Youth Risk Behavior Survey will be utilized for the
evaluation.
Summary results of preand post-test measures
06/30/2013
3. Organize transportation for the Washington Unified student
body to attend larger FREAKS programs. This will be offered at
least twelve times over the course of the grant, ending June 30,
2013.
Track number and
frequency of attending
students
06/30/2013
Primary Intervention 2: University-level FREAKS Program
Consultant Activities
1. Conduct weekly FREAKS programming for University and
community participants in an effort to reduce substance use.
2. Conduct health-risk behavior surveillance with participating
college-aged students to determine program effectiveness. A
modified version of the CDC-Youth Risk Behavior Survey will
be utilized for the evaluation.
Deliverables/Tracking
Measures
FREAKS program
Summary results of pre- and
post-test measures
Timeline
1/30/2013
06/30/2013
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