Healthy Choices Fund
Application Form (2017-2018)
Read Instructions
CONTACT INFORMATION
Project Title:
Name of Organization:
Contact Person:
Mailing Address:
Postal Code:
Email Address:
Fax Number:
Phone Number:
What is the best way to communicate with you?
Phone ☐
Fax ☐
Email ☐
APPLICATION DEADLINE: 5:00 PM, MARCH 15, 2017
PROJECT INFORMATION
Project Start Date:
Click here to enter a date.
Project End Date:
Click here to enter a date.
Project Description (Please include in 300 words or less – project goal; activities for each goal;
your partners and their role in the project; program evaluation (how will you evaluate your
program and how will you know your program made a difference)):
Note: Interim and final reports with pictures are required.
If you would like this information in another official language, contact us at 1-855-846-9601.
Si vous voulez ces informations dans une autre langue officielle, téléphonez-nous au 1-855-846-9601.
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Healthy Choices Fund
Application Form (2017-2018)
FUNDING INFORMATION
Total funding applied for: $0 (Zero Dollars and Zero Cents)
Budget
Anticipated Project Costs
A. Materials and Supplies:
(Including, but not limited to, all
program/workshop expenses such as
program supplies, advertising, hall rental,
snacks and drinks, printing, etc.)
$
B. Staff Expenses:
( # of staff x days x $/day)
$
C. Facilitator Fees and Expenses:
(Including, but not limited to, travel and
accommodation)
$
D. Subtotal (A+B+C):
$
E. Administration (5% of D):
$
Total Anticipated Project Cost (D+E):
$
APPLICATION CHECKLIST
☐ You have read the Healthy Choices Fund Instructions and are eligible to apply.
☐ The application form is complete and includes:
☐ liability insurance that expires no sooner than March 31, 2018;
☐ letter of good standing from Societies Registrar or Letter of Incorporation; and
☐ 3 letters of support organizations that understand and demonstrate how they will
support you project.
☐ Identification of additional funding applied for / received for this project.
Send completed applications to: [email protected] or Fax: (867) 873-3585.
Mailing Address:
Manager, Health and Wellness Promotion
Department of Health and Social Services
Government of the Northwest Territories
Phone: (867) 767-9064 ext. 49230
Website: www.hss.gov.nt.ca
If you would like this information in another official language, contact us at 1-855-846-9601.
Si vous voulez ces informations dans une autre langue officielle, téléphonez-nous au 1-855-846-9601.
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Healthy Choices Fund
Application Form (2017-2018)
Instructions
The Healthy Choices Fund supports eligible applicants that maximize the impact of health
promotion and prevention activities that support individuals, families, and communities to make
positive lifestyle choices in the Northwest Territories.
Eligibility for Access to Fund:
Eligible projects are those that meet all of the following criteria:

Provide a tangible service or support at the community, regional or territorial level.

Demonstrate the potential to improve health outcomes for residents in a tangible and
measurable fashion.

Whose activities link to existing community or regional based programs.

Demonstrate the ability to develop meaningful partnerships with other organizations and
support an integrated approach in promoting healthy choices.

Be located in the Northwest Territories.
Priority of competing projects:
If there are multiple, competing projects, and there is insufficient funding to provide support for
each project, priority will be given to projects that:

Demonstrate partnerships.

Demonstrate sustainability.
Eligible applicants are:

Aboriginal governments in the Northwest Territories recognized by the Department of
Aboriginal Affairs and Intergovernmental Relations.

Community governing authorities (Band Council, Metis Local, Charter Community or
municipal council).

Non-government organizations that can demonstrate partnership or support from an
Aboriginal or community governing authority.

The Health and Social Services Authorities.
If you would like this information in another official language, contact us at 1-855-846-9601.
Si vous voulez ces informations dans une autre langue officielle, téléphonez-nous au 1-855-846-9601.
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