Application #_________________
For Office Use Only
2014 COMMUNITY HEALTH
GRANTS APPLICATION
Total Project Cost:
Minus Other Related Funding:
Minus In Kind Support:
Total Funding Requested:
$__________
$ __________
$__________
$__________
Deadline:
September 19, 2014
First Time Applicant
No
1. TITLE OF PROJECT
2. APPLICANT INFORMATION
Organization
Applicant (Contact Person)
Street Address
City
Province
Postal Code
Telephone
Fax
Email
3. HOST/SPONSOR ORGANIZATION (IF DIFFERENT FROM ABOVE)
Organization
Address
City
Province
Postal Code
Telephone
Fax
Email
4. ORGANIZATIONAL PROFILE
Give a brief profile of your organization, including what your organization does, as well as the current programming
and services that are relevant to the project and the client group that you serve.
5. BRIEF PROJECT DESCRIPTION
Describe the project and explain how it aligns with the vision and mission of CBCF – Atlantic Region. Explain which
area of focus your project will address (health promotion, early detection, effective treatment). Please limit your
response to 100 words or less.
5.1 Do other organizations offer programs or services similar to this project? If so, how does your project differ? Is
there potential for a similar approach in other parts of the Atlantic Region (i.e. can this project be duplicated for benefit
in other areas)?
CANADIAN BREAST CANCER FOUNDATION – ATLANTIC REGION
COMMUNITY HEALTH GRANTS APPLICATION 2014
5.2 If this application is for the purchase of equipment, what percentage of time will the equipment to be purchased be
used for breast cancer patients?
6. COMMUNITY OF INTEREST
Describe the community or group of people this project will focus on. Include details such as the estimated population
size, geographic location, age range, cultural background, language community and other shared characteristics. Pointform is acceptable.
7. PROJECT NEED
Describe why there is a need for this project and how the project will meet this need.
8. PROJECT IMPACT
What overall results/outcomes will be achieved with this project? What impact will this project have on the community
of interest?
9. PROJECT OBJECTIVES AND IMPLEMENTATION PLAN
What objectives will you use to achieve the desired result(s) described in question 8? Objectives should be specific,
measurable, action oriented, realistic and achievable in a specific period of time (maximum one year). For each
objective listed, provide the activity which will be used to meet that objective and the timeline to accomplish this. The
activities should describe in detail where you will spend time and money to achieve the objectives.
Objective
Activity
Timeline
10. KNOWLEDGE TRANSLATION
CBCF – Atlantic Region places a priority on dissemination and knowledge exchange for the purpose of broadly
sharing project learnings. Describe how the lessons learned, and the knowledge gained from your project will be
shared with the appropriate audiences.
11. EVALUATION
Please describe how you will evaluate the objectives from Question 9.
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CANADIAN BREAST CANCER FOUNDATION – ATLANTIC REGION
COMMUNITY HEALTH GRANTS APPLICATION 2014
12. DETAILED BUDGET CALCULATIONS
For activities described in Question 8, please provide a detailed budget of items required to complete those activities.
Please list all expenses related to the project, including in-kind and expenses which will be covered by other
funding. The in-kind and other funding will be deducted from the total cost of the project in another section of this
application. See Appendix A for a Sample Budget.
A. Supplies and expenses (list each item and expense)
i.
Office Supplies/Office Equipment (phone/fax, copier)
ii.
Staffing (Salaries, Research Fees) Detailed job descriptions must be
provided for any staff who will be funded through this project
iii.
Rent
iv.
Training
v.
Travel
vi.
Honorarium
B. Educational and Publication
i.
Materials Production
ii.
Conference Fees
iii.
Resource Materials
Amount ($)
Amount ($)
C. Capital Equipment
Amount ($)
All requests for capital equipment must include a quote and a letter of
approval from the institution’s senior executive. The letter should indicate
that the program meets with the aims of the institution and can be sustained in
the future by that institution.
D. Other Costs (Please Specify)
Amount ($)
10.1. DETAILED BUDGET SUMMARY
A. Supplies and Expenses
$
B. Educational and Publication
$
C. Capital Equipment (Requests for capital
equipment will be considered to a maximum of
$75,000)
$
D. Other Costs
$
Total Project Cost (Transfer this amount to the top left of
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CANADIAN BREAST CANCER FOUNDATION – ATLANTIC REGION
COMMUNITY HEALTH GRANTS APPLICATION 2014
the front page of the application beside Total Project $
Cost)
13. OTHER FUNDING RELATED TO THIS PROJECT
Please list all sources of funding received or anticipated for this project. Suggestions of sources for co-funding are:
hospital foundations, service clubs, community foundations, women’s clubs and/or corporate donors.
Source
Date Received or Expected
Total Other Funding (Transfer this amount to the top left of the
front page of the application beside Other Related Funding)
Amount ($)
$
14. IN-KIND SUPPORT
In-kind support refers to goods and services given to the project at no charge by the Host Organization, project partners
or other contributors. This information demonstrates the community support for the project. (In-kind support should be
listed in Section 10 as part of the detailed budget summary).
Source
Explanation
Date Received or Expected
Approximate Value ($)
$
Total In-Kind Support
(Transfer this amount to the
top left of the front page of
the application beside InKind Support)
15. BUDGET SUMMARY
Total Project Cost (from Section 10.1)
$
Minus Other Funding (from Section 11)
$
Minus In-Kind Support (from Section 12)
$
TOTAL FUNDING REQUESTED (Transfer this $
amount to the top left of the front page of the application
beside Total Funding Requested)
16. SUSTAINABILITY
A project is sustainable when it continues to deliver benefits to the community of interest and/or other stakeholders for
an extended period after the funding support has been terminated. What plan (organizational, financial and/or
community) is in place to ensure this project continues to deliver benefits?
17. ADMINISTRATION OF FUNDS
What mechanism is in place to oversee project expenditures (i.e. Board, steering committee, committed staff, etc)?
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CANADIAN BREAST CANCER FOUNDATION – ATLANTIC REGION
COMMUNITY HEALTH GRANTS APPLICATION 2014
18. APPLICANT’S GRANT REQUEST HISTORY (Please check as appropriate)
Is this your first application for funding from the Canadian Breast Cancer
Foundation – Atlantic Region? If no, please provide a description of the type of
 Yes
 No
funding requested and/or received, when and if you were funded.
Are you or your organization receiving CBCF funding at this time? If yes, please
attach a status report on your current project including a financial statement.
 Yes
 No
Have you received a grant from another organization(s) in the past related to
breast health/cancer?
 Yes
 No
Have you submitted a proposal for this work to another funding organization? If
yes, please identify the funding organization and the date of the application.
 Yes
 No
19. APPLICANT AND HOST/SPONSOR ORGANIZATION SIGNATURE(S) OF AGREEMENT
I the undersigned agree and certify that the statements contained in this application are true, complete and
accurate to the best of my knowledge.
_____________________________________
Print
_____________________________________
Signature of Applicant
_________________________
Date
_________________________________________________
Print
__________________________________________________
Signature from Host/Organization that will Administer Funds
__________________________
Date
SUBMISSION CHECK LIST
 Did you answer every question listed on the Application?
 Did you include all of the following:
 A signed original copy of the application
 Twelve (12) copies of the signed original application
 At least two (2) letters of support from partnering organizations
Send all copies to:
Mary Wilson, Grant Allocations Officer
Canadian Breast Cancer Foundation - Atlantic Region
417-5251 Duke Street
Halifax, NS B3J 1P3
APPLICATIONS MUST BE RECEIVED ON OR BEFORE SEPTEMBER 19, 2014 AT 4:30PM
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CANADIAN BREAST CANCER FOUNDATION – ATLANTIC REGION
COMMUNITY HEALTH GRANTS APPLICATION 2014
APPENDIX A
SAMPLE BUDGET
1. Supplies and expenses (list each item and expense)
Office Supplies/Office Equipment (phone/fax, copier)
vii.
viii.
Amount ($)
$1,000
Staffing (Salaries, Research Fees) Detailed job descriptions n/a
must be provided for any staff who will be funded through this
project
ix.
Rent
$1,000 (in kind)
x.
Training
$2,500
xi.
Travel
$1,000
xii.
Honorarium
$1,000
iv.
2. Educational and Publication
Materials Production
Amount ($)
$1,000
v.
Conference Fees
n/a
vi.
Resource Materials
$1,000
3. Capital Equipment
All requests for capital equipment must include a quote and a letter n/a
of approval from the institution’s senior executive. The letter should
indicate that the program meets with the aims of the institution and can
be sustained by future funding from that institution.
4. Other Costs (Please specify)
Amount ($)
Amount ($)
n/a
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CANADIAN BREAST CANCER FOUNDATION – ATLANTIC REGION
COMMUNITY HEALTH GRANTS APPLICATION 2014
10.1 DETAILED BUDGET SUMMARY
i.
Supplies and Expenses
$6,500
ii.
Educational and Publication
$2,000
iii.
Capital Equipment (Requests for capital
equipment will be considered to a maximum of
$75,000)
$0
iv.
Other Costs
Total Project Cost (Transfer this amount to the top left of
the front page of the application beside Total Project Cost)
$0
$8,500
11. OTHER FUNDING
Please list all sources of funding received or anticipated for this project. Suggestions of sources for co-funding are: hospital
foundations, service clubs, community foundations, women’s clubs and/or corporate donors.
Source
ABC Company
DEF Company
Total Other Funding (Transfer this amount to the top left of the front
page of the application beside Other Related Funding)
Date Received or Expected
April 30, 2015
April 30, 2015
Amount ($)
$1,000
$ 500
$1,500
12. IN-KIND SUPPORT
In-kind support refers to goods and services given to the project at no charge by the Host Organization, project partners or other
contributors. This information demonstrates the community support for the project. (In-kind support should be listed in Section 10
as part of the detailed budget summary).
Source
Office Support Co.
Explanation
Rental of office space
Date Received or Expected
November 30, 2014
Approximate Value ($)
$1,000
$1,000
Total
In-Kind
Support
(Transfer this amount to the
top left of the front page of the
application beside In-Kind
Support)
13. BUDGET SUMMARY
Total Project Cost (from Section 10.1)
$8,500
Minus Other Funding (from Section 11)
$1,500
Minus In-Kind Support (from Section 12)
$1,000
TOTAL FUNDING REQUESTED (Transfer this amount to
the top left of the front page of the application beside Total
Funding Requested)
$6,000
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