Youth-to-Youth Grant Application | Buffalo County Youth Advisory Board

Name of Group *

Title of Project *

Number of youth that will participate (include age range of participants): *

Youth Contact and Title *

Youth Address, City, State, Zip *

Youth Email Address *

Youth Phone Number *

Youth Age *

Adult Contact and Title *

Adult Address, City, State, Zip *

Adult Email Address *

Adult Work Phone *

Adult Home Phone *

Sponsoring Organization *

Fiscal Agent Representative *

A fiscal agent can be any non-profit agency such as schools or churches, recognized as such by the state. The funds awarded to you can simply pass through the fiscal agent. For example, if you are awarded $500, a check is issued to the fiscal agent, you then access all $500 from the fiscal agent. The fiscal agent keeps track of receipts and how the money was spent.

Fiscal Agent Address, City, State, Zip *

Fiscal Agent Work Phone *

Fiscal Agent Home Phone *

Fiscal Agent Email Address *

The undersigned adult contact person and representative of the sponsoring organization hereby attest to the fact that this project proposal was initiated and prepared by youth, and this project will be planned and carried out by youth. *

Yes

No

Adult Project Leader Signature and Date *

By submitting your name and date, you are verifying your consent to submit this application.

Sponsoring Organization Representative Signature and Date *

By submitting your name and date, you are verifying your consent to submit this application.

Will your project address one of these Buffalo County strategic directions? (Check all that apply. Must select one to qualify for grant award.) *

Healthy Eating/Active Lifestyle

Eliminating Health Disparities

HIGH IMPACT PREVENTION (Mark One or More):

Alcohol or Tobacco

Other Drugs

Mental Health

Teen Sexual Activity

Adult Dementia/Alzheimer's Disease

INJURY-FREE LIVING (Mark One or More):

Youth/Adult Seat Belt Use

Child Abuse

Domestic Violence

Youth Suicide

HEALTHY HOMES AND SUSTAINABLE COMMUNITIES (Mark One or More):

Quality Rentals

Affordable Housing

Financial Responsibility

Please email proof of your 501(c)3 status. If you are not a 501(c)3, please name your fiscal agent below, and supply proof of 501(c)3 status. Buffalo County Community Partners is also willing to serve as your fiscal agent, if needed.

What is the title of your project? *

What is your project idea? *

Where will your project take place? *

When will your project begin and end? *

Will you need additional advice or assistance to help complete this project? *

Yes

No

If so, what kind?

Are there special permission slips, insurance coverage, etc., needed for this project? *

Yes

No

If so, please explain.

How will your project help the community? *

How did your group determine that this is an important community need? *

Who/What is your project serving? (Please check all that apply) *

Young Children

People who are sick

A neighborhood or community

Other youth

The environment

The elderly

People who are disabled

Low-income families

Other

If you chose "other," please specify.

Approximately how many people will receive service through this project? *

Who wrote this proposal? *

Describe the group that is applying for the grant. If the group is not formally organized, please describe how you came to work on the proposed project.

How have youth been involved in planning this project? *

How will youth be involved in implementing this project? *

List of Youth Participants *

Please include name, age and affiliation (member, president, chair, etc.) for each youth.

What do you think you will learn about your community from your project? *

What reflection activities will you use during your project to be aware of your progress? *

How will you share the things you learn with others (for example, writing, pictures, presentations, etc.)? *

Is your group interested in giving a presentation in the community? *

Yes

No

How will you measure your success during your project, and when it's done? *

How will the group celebrate a job well done? *

How much will your project cost? *

How much money are you requesting from the YAB program? *

Please remember that Youth-to-Youth Grants will not be awarded in excess of $1,000.00

Who will oversee the use of these funds? *

What other donations of funds, time, talent or materials have you received for this project?

Please included the estimated value for each donated item.

Total Estimated Value of Donated Items

Please list your Operational Costs (supplies, materials, rental, etc), and the amount your are requesting. *

Total Operational Costs *

Please list your Transportation Costs (if necessary), and the amount you are requesting. *

If no transportation costs are necessary, please enter N/A.

Total Transportation Costs *

If transportation costs are not necessary, please enter N/A.

Please describe your Recognition Costs (no more than 15% of grant), and the amount your are requesting. *