HOI FY08?09 Rev. 1/09--Effective 2/1/09 Cov er Page
HEALING OUR ISLAND COMMUNITY FUND 2009
GRANT PROPOSAL COVER PAGE
APPLICANT INFORMATION
Eligible applicants are community?based groups in Hawai`i County dedicated to building a healthy,
safe, and supportive community through collaborative community?focused projects.
Name of your group
Project or event title
Complete Mailing Address (Number, Street or PO Box, Suite, Town, Zip Code)
FUNDING REQUEST
Has your group or organization ever received a Healing Our Island grant?
Yes
No
Please skip the next question if you answered ?No? above
The same project that was previously funded
This application seeks funding for
A new project or program
$
Amount Requested (Maximum $2,000.00)
Project/Event Date
Date Funding Needed
PROJECT PLANNING TEAM
Project Lead Contact Name
Telephone Number
Email Address
Complete mailing address: Number and Street or PO Box, Town, Zip Code
Second Project Contact Name
Telephone Number
Email Address
Complete mailing address: Number and Street or PO Box, Town, Zip Code
PROJECT BUDGET MANAGERS
First Budget Manager Name
Telephone Number
Email Address
Complete mailing address: Number and Street or PO Box, Town, Zip Code
Second Budget Manager Name
Telephone Number
Email Address
Complete mailing address: Number and Street or PO Box, Town, Zip Code
Hawai`i County is an Equal Opportunity Provider and Employer
HCRC USE ONLY
Grant ID No.
Total possible points for Project Description: 40
HOI FY08?09 Rev. 01/09--Effective 2/1/09 Project Des cription Page 1
Healing Our Island Community Fund ? Project Description
Name of your Project:
1.
Describe where your project will take place:
2.
When will your project take place?
3.
Provide a brief summary of what you intend to do and how you will use Healing Our Island funds:
4.
Are members of your target audience involved in project planning?
Yes (please explain how they are involved)
No (please explain why they are not)
5.
How many people do you expect to reach directly through this project?
6.
How will you measure participation? (e.g., sign?in sheet; ticket stubs; registrations; etc.)
Total possible points for Project Description: 40
HOI FY08?09 Rev. 01/09-Effective 2/1/09 Project Des cription Page 2
7.
Your proposed project is: (please select one)
A one?time event
Monthly event
Weekly event
Annual event
Semi?annual event
Ongoing project
Other: (Please explain)
8.
Check the region(s) where the majority of the people you intend to reach through your project reside:
Hamakua
South Kona
North Hilo
North Kohala
Kau
South Kohala
Puna
North Kona
South Hilo
9.
Check the category or categories that best describes the people you intend to reach through your
project:
Families
Youth, 0?5
Other (please describe):
Adults
Youth, 6?11
Community?at?large
Youth, 12?18
People in treatment/recovery from substance abuse
10.
Which category best describes your project? Please check all that apply.
Anti?drug education
Fine and performing arts
Anti?drug awareness
Mentoring
Community coalition building
Natural resources preservation and awareness
Community service project
Parenting skills
Cultural heritage
Sports and recreation
Faith?based activity
Training/education
Disaster preparedness
Other (please describe):
Total possible points for Project Description: 40
HOI FY08?09 Rev. 01/09-Effective 2/1/09 Project Des cription Page 3
11.
Please check the prevention strategy* or strategies your project will use:
Information Dissemination: This strategy provides awareness and knowledge of the nature
and extent of alcohol, tobacco, and other drug use, abuse, and addiction and their effects on
individuals, families, and communities.
Prevention Education: This strategy aims to affect critical life and social skills, including
decision making, refusal skills, critical analysis (for example, of media messages), and
systematic and judgmental abilities.
Providing Alternatives: This strategy provides for the participation of targeted populations
in activities that exclude alcohol, tobacco, and other drug use. Constructive and healthy
activities offset the attraction to, or otherwise meet the needs usually filled by, alcohol,
tobacco, and other drug use.
Community?Based Process: This strategy aims to enhance the ability of the community to
provide prevention and treatment services to alcohol, tobacco, and other drug use disorders
more effectively. Activities include organizing, planning, enhancing efficiency and
effectiveness of services implementation, interagency collaboration, coalition building, and
networking. Building healthy communities encourages healthy lifestyle choices.
Environmental (community attitudes) Approach: This strategy sets up or changes written
and unwritten community standards, code and attitudes?influencing incidence and
prevalence of alcohol, tobacco, and other drug use problems in the general population.
*Source:
Hawai?i State Department of Health
12.
Please explain briefly how your project incorporates the prevention strategy/strategies above.
Include a description and source of any anti?drug information you plan to use in your project.
13.
What impact do you expect your project to have on your community and how will you know
whether the project outcomes met your expectations?
Total possible points for Project Budget: 30
HOI FY08?09 Rev. 01/09-Effective 2/1/09 Project Budge t
HEALING OUR ISLAND COMMUNITY FUND
PROJECT BUDGET
IMPORTANT: This budget form is required?do not submit your budget in a different format.
Project name:
Indicate below how different funding sources will be allocated
Project Expenses ? please list your expenses below in detail and explain
how the items will be used. See example in line 1 below:
Amount
Budgeted
(A)
Healing Our
Island
(B)
Other
Source
(B)
Describe your other
sources of funding
100 T?shirts @ $4 each + $50 set?up ? distribute to all participants
$450
$400.00
$50.00 Member contributions
1
2
3
4
5
6
7
8
9
10
11
12
TOTAL SOURCE OF FUNDS (A)+(B)
TOTAL BUDGETED EXPENSES
Important: your total expenses should not exceed your sources of funds
Non?cash Contributions (description)
Cash Value
Value of Volunteer Hours
$
Number of volunteers:
$
Total number of hours donated by the volunteers:
$
Value of volunteer time: Total hours x $19.51: $
Total:
$
Total possible points for Community Group Description: 30
HOI FY08?09 Rev. 01/09-Effective 2/1/09 Community Group Description
Healing Our Island Community Fund ? Community Group Description
Name of your Group:
Name of your Project:
1
Describe your group. When, why and how did you get started?
2.
In which County District is your group located? Please select just one:
Hamakua
North Kona
Puna
North Kohala
South Kona
South Hilo
South Kohala
Kau
North Hilo
3
Please list the names of the members of your project planning committee. Attach a list if necessary.
4
If applicable, please list the names of any other organization(s), or community groups that are
partnering with you on this project. Collaboration is highly recommended.
5
Please explain the roles your collaborating partners will have in your project.
HOI FY08?09 Rev. 01/09-Effective 2/1/09 Signed
Agreement
Healing Our Island Community Fund Application and Agreement
Name of Group:
Name of Project:
Our signatures below indicate that we and all those involved in the planning group and project
referenced above have agreed to the project plan and budget outlined in this application. In
addition, we have read the program guidelines, we know how to contact our Healing Our Island
district contact for assistance, and we understand and will comply with the Healing Our Island
Community Fund guidelines including the following:
1.
Our project or program has a direct anti?drug component or message, and we will conduct an
alcohol? and drug-free project or program;
2.
If awarded, we will use the Healing Our Island logo in project materials, where practical;
3.
If awarded, we will announce our award in a press release that we submit to either one of the
following daily newspapers: Hawai`i Tribune?Herald or West Hawai`i Today;
4.
If awarded, we will use the grant funds exactly as we propose in this application, or as specified in
writing by the County of Hawai`i; If we find that we need to change any part of our proposed project
or use of grant funds, we will submit a brief written request to the Healing Our Island Review
Committee in care of the Hawai`i County Resource Center (HCRC) and will not proceed with the
project until we receive notification from the HCRC;
5.
If awarded, we will submit our Healing Our Island Final Report including all original receipts of
project expenditures and a copy of our press release to the HCRC;
6.
If awarded, we understand that the source of the grant is public funds and therefore our project
information may be shared publicly (personal telephone numbers and addresses will not be
disclosed).
7.
If awarded, we understand that the County of Hawai`i shall in no way be held liable for any claims,
damages, causes of action, or suits resulting from any activities of the grantee or its contractors. The
grantee shall indemnify, defend, and save harmless the County, the Department of Research and
Development, and their officers, agents, and employees from any liability, actions, claims, suits,
damages, or costs arising out of or resulting from the acts or omissions of the grantee, its officers, its
officers, employees, agents, or sub?contractors occurring during, or in connection with, activities
that may be funded, in whole or in part, from grant funds provided to the grantee under this
agreement.
All four signatures of the individuals listed on the Grant Proposal Cover Page are required here:
1
Project Lead:
Print name legibly
Signature Date
2
Second Project
Contact:
Print name legibly
Signature Date
3
First Project
Budget Manager
Print name legibly
Signature Date
4
Second Project
Budget Manager
Print name legibly
Signature Date