National Council on Independent Living Path to Empowerment for Consumers with SCI FULL GRANT APPLICATION for Centers for Independent Living, Statewide Independent Living Councils, and Independent Living Associations - Organization Name: - Applicant Name and Title: - Mailing Address: - City, State, Zip: - Applicant Email Address: - Organization Website Address: - Project Title: - *Amount Requested ($10,000 - $25,000 maximum): - Application Category (Check the category that best describes your program/project.): [ ] Independent Living [ ] Rehabilitation [ ] Employment [ ] Assistive Technology [ ] Arts, Sports & Recreation [ ] Education *Note: Funding cannot be used for staff salaries. Staff/personnel costs should be reflected in your total program budget, but funds cannot be requested for those costs through this grant application. 1. Provide your organization’s mission statement and a brief history: 2. Number of individuals served by your organization in the past year/fiscal year: 3. Serving individuals with SCI: a) How many individuals with SCI does your organization serve in a year? b) How many total individuals do you estimate your proposed program/project will serve? c) How many individuals with SCI do you estimate your proposed program/project will serve? 4. Project Description: a) Is this a new or continuing program/project? b) Describe the proposed program or project, its purpose, goals, and specific activities: c) Define the proposed outcomes of the program/project – that is, what will the project accomplish? What will be the impact on the quality of life of people with spinal cord injuries? Please include both objective (numbers on individuals served, pieces of equipment loaned or purchased, etc.) and subjective (observation from programs, expanded programs, consumer surveys, etc.) outcomes. 5. Project Evaluation: Please describe how you will define and assess the effectiveness and evaluate the overall success of your program/project: 6. Describe how the project will maximize consumer participation and establish collaboration with other relevant groups in the community: 7. Budget: Reminder: Funding cannot be used for staff salaries. Staff/personnel costs should be reflected in your total program budget, but funds cannot be requested for those costs through this grant application. Program Fees: Program fees/charges that are normally either charged to clients, subsidized via some other sources (like Voc Rehab, etc.) or written off when a client has no resources, are appropriate inclusions in your budget as long as they are clearly aligned with clients with SCI who would receive the services. This approach is essentially “scholarshipping” the clients for the services provided. Line items should not support general operating funds; rather, they must support programs directly serving those with SCI. - What is the total budget for the entire project? $ - What is the total amount of grant funds requested from NCIL? $ - In the table below, please provide a brief description of each line item applicable to - your program/project and the amount requested from NCIL for each category. Table Column 1 - Category and Brief Description Column 2 - Grant Funds Requested - Program Supplies Description: - Program Supplies Grant Funds Requested: - Program Fees Description: - Program Fees Grant Funds Requested: - Travel Description: - Travel Grant Funds Requested: - Equipment Description: - Equipment Grant Funds Requested: - Other Description: - Other Grant Funds Requested: - Other Description: - Other Grant Funds Requested: - TOTAL FUNDS REQUESTED: Will any other sources of funds be used to support this program/project? [ ] Yes [ ] No If yes, please list all other funding sources for this program/project, including anticipated applications. Please include the organization, amount received (or anticipated) and date received (or anticipated). Please note that as per the terms of NCIL’s contract with the Craig Neilson Foundation, organizations selected for pass-through funding are required to match 5-10% of their subgrant amount. 8. Program Sustainability: How will you ensure the continuation of this program after the end of the NCIL grant? 9. Please provide any additional information that will help reviewers understand your application. 10. Attachments [ ] Organizational operating budget, including revenue and expenses [ ] W-9 Form [ ] IRS 501 (c)(3) determination letter