APPLICATION FORM COMMUNITY FOOD SECURITY AND FOOD EDUCATION PROGRAM

Transcription

1 APPLICATION FORM COMMUNITY FOOD SECURITY AND FOOD EDUCATION PROGRAM Section 1 - Applicant Information Full Name (including middle name): Organization Name: Mailing Address: Village/Town/City Province Postal Code Telephone No. / Cellular Phone No. Fax No. Address Type of Organization. Choose one and complete the required information: Individual Proprietorship (if you file to Canada Revenue Agency as an individual) Social Insurance Number: Incorporated Company (if you file to Canada Revenue Agency as a corporation) (This number can be found on your tax forms and is required under the authority of the Income Tax Act) Revenue Canada Business Number: Partnership (if you file to Canada Revenue Agency as a partnership.) Please include Revenue Canada Business Number Revenue Canada Business Number: Registered Charitable Organization / Not for Profit Please include the charity registration number Registration number: Name of all Partners (for partnerships) % of Ownership (Must total 100%) Community Food Security and Food Education Program, 2017 Page 1 of 6

2 Section 2 Project Information Project Title: Project Start Date: Project End Date: Total Weeks: Grant Amount Requested ($10,000 maximum) $ Primary region where project will be delivered Kings County Queens County Prince County Province-wide 1. Indicate the program objective that your project will address. Select only one Primary objective and up to two Additional objectives. Primary Additional Program Objectives Increase availability of fresh local food on menus in schools and/or licensed early childhood centres Promote good nutrition and healthy food choices Build community self-reliance and collaboration Provide community-based food learning experiences (e.g., food literacy) Link farmers to consumers Enhance the pride and joy of growing, preparing, and eating food Increase knowledge about local food on PEI Increase community capacity to address community food security Provide opportunities for vulnerable or marginalized communities on PEI. 2. Executive Summary of Project (maximum 500 words) Provide a brief summary of the project that may be used as a project description for the grant adjudication committee and communication purposes if your application should be successful. Please note that all approved projects will be included in the Department s public communication platforms (e.g., website, social media, etc.) Community Food Security and Food Education Program, 2017 Page 2 of 6

3 3. Project Objectives Briefly describe the issue your project is designed to address. If the project has been offered before, briefly describe the results and any changes that have been made to the project to improve outcomes for participants. 4. Does the project intend to increase the availability of fresh local food on lunch menus in schools and/or licensed early childhood centres? Y N If yes, explain how: 5. Please indicate who will participate in and/or benefit from the project (check all that apply) Aboriginal people Newcomers to Canada Refugees Children (pre-school) Students (K-12) English / French University/College students Other (describe in box below) Urban residents Rural residents Senior citizens (55+) Individuals with a disability Individuals with a low income (i.e., living in or close to poverty) Community Food Security and Food Education Program, 2017 Page 3 of 6

4 6. Major Project Activities and Timelines Activity Description Start Date (YY-MM-DD) End Date (YY-MM-DD) 7. How will you measure and evaluate the overall success of the project? How will you evaluate the results experienced by participants? (attach extra page if needed). 8. If the grant is awarded, describe how you will recognize the support of the PEI Department of Agriculture and Fisheries? Community Food Security and Food Education Program, 2017 Page 4 of 6

5 BUDGET INFORMATION Revenue Source $ Amount Confirmed ( ) Pending ( ) Total Revenue Budget: $ Expense $ Amount Total Expenses: $ By submitting this form for project funding, I/We: understand that personal information on this form is collected under Section 31c of the Freedom of Information and Protection of Privacy Act R.S.P.E.I c. F as it relates directly to and is necessary for program being delivered; agree that information provided for purposes of the program may be shared with the Canada Revenue Agency as it pertains to any potential taxable benefits; agree to participate in an evaluation and/or audit of the program; understand that my application will be reviewed by a committee composed of representatives from government and the community; understand that projects funded will be communicated through the Department s public and social media channels; understand that failing to comply with all application requirements may delay the processing of the application, or may render me ineligible for receiving assistance under the program; understand that the Social Insurance Number, Business Number and/or Charity Registration Number is collected under the authority of the Income Tax Act for the purposes of reporting income; acknowledge that my/our completing this application form and by receiving advice from PEIDAF or other program delivery agent does not oblige PEIDAF or other delivery agents to provide funding; understand that expenses incurred prior to the submission of an approved application are not eligible for assistance under this program; agree that a completed Final Report including financial verification will be provided to the PEI Community Food Security and Food Education Program, 2017 Page 5 of 6

6 Department of Agriculture and Fisheries. understand that successful applications will receive 80% of the total grant at the beginning of their project. The final 20% will be released when the final report and final expenditure report (with receipts) has been received by the Department of Agriculture and Fisheries. understand that financial claims must be submitted no later than March 15, I, certify that the information given on this application is to the best of my knowledge complete, true and accurate. Name of Applicant/ Signing Officer Signature of Applicant/Signing Officer Date (Please print) Section 4 - Submitting the Application Once you have completed this application please a signed copy in PDF to: agr-feedback@gov.pe.ca Subject line: CFSFE Program Application Questions? Please agr-feedback@gov.pe.ca Date Application Received (Office Use Only) Initials: Approved? Y N Date: Community Food Security and Food Education Program, 2017 Page 6 of 6