Aboriginal Healing & Wellness Grant Application Form

ABORIGINAL HEALING AND WELLNESS 2017 GRANT APPLICATION Deadline: Friday, May 12, 2017

ORGANIZATIONAL OVERVIEW Full Legal Name of Organization

Street Address

Postal Code Mailing Address (if different from street address) Primary Contact Person Name Title

Telephone Email Website Address

Secondary Contact Person Name Title

Telephone Email

Under what legal name is your Organization incorporated How is your Organization incorporated Society Act (British Columbia) Co-operatives Act (British Columbia) Other, please specify: Please provide your incorporation number (e.g. BC Society Number or equivalent) Is your Organization in good standing under its incorporating statute (e.g. for a BC Society or Co-operative Yes this would be the case if your annual reports to the Registrar of Companies were up-to-date) No Is your Organization registered with Canada Revenue Agency as registered charity? Yes No If a registered charity, please provide your official tax receipt number as issued by Canada Revenue Agency Are staff permitted to be voting members on the Society Board? Yes No Are any board directors remunerated for being a director? Yes No

ELDER SERVICES PROGRAM Briefly describe your Elder services program for which you are requesting a grant. Include in this description the main groups that your Elder Services Program serves (e.g. Aboriginal people, families, pre-school children, youth, people living with mental health and/or addictions, people experiencing homelessness, seniors/elders, etc.)

How long have you been providing Elder services for which you are seeking City funding? years Estimate the number of individuals using your Elder services program Percentage of these individuals who use the Elder services program that live in Vancouver %

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STAFFING INFORMATION Please provide the following information for Elders who are involved in your Elder Services Program for which you are seeking City funding in this application Elder Regular/ Total compensation (honorarium, Type of compensation average contract, salary & benefits) hours of provided for fiscal year starting in work per 2016 (actual) 2017 (projected) Honorarium Contract Salary & week Benefits $ $ $ $ $ $ $ $ $ $ TOTAL $ $

FINANCIAL INFORMATION Budget for your Elder Services Program REVENUE SOURCES For the fiscal year beginning in: 2017 Include the value of in-kind donations. List each 2016 Fiscal Year 2017 Fiscal Year Confirmed? separate revenue source, including specific Provincial (Actual) (Projected) Yes or No Ministries, Agencies and Authorities, Federal Departments, Foundations, etc. City of Vancouver AH&W Grant

TOTAL REVENUES

EXPENDITURES Honorariums, Contracts, Salary & Benefits (for Elder Services Program only) Program Expenses Administrative Expenses Other Expenses TOTAL EXPENDITURES

Operating Budget for the Entire Organization NOTE: The application form requires an Operating budget for the Entire Organization. The template for the Operating Budget for your entire organization is in a separate Excel document.

You must remember to include the Operating budget with your hard copy application and remember to email it to us with your electronic application form.

EVALUATION As part of the commitment to the City’s Aboriginal Healing and Wellness Project, we want to understand the impact of Aboriginal Healing and Wellness activities for the urban Aboriginal population and to assess the effectiveness of both what we are accomplishing through the Aboriginal Healing and Wellness Project, as well as how we are accomplishing it – including partnerships, collaborations, and processes.

We will participate in the City’s Aboriginal Healing and Wellness Project evaluation process: Yes No

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THIS PAGE NEEDS TO BE COMPLETED BY HAND FOR YOUR HARD COPY SUBMISSION

SIGNATURES

By signing this application, you are indicating agreement with the following statement and conditions:

We certify that, to the best of our knowledge, the information provided in this civic grant request is accurate and complete and is endorsed by the organization which we represent. If our organization receives a civic grant, we agree to the conditions set out below and to any other conditions approved by Council. We understand that this application and supporting materials are public documents, and that any member of the public may have access to all or any part of them.

(Signature of two signing officers of the Board of Directors of the organization, NOT staff)

______Signature Title Date

Print Name: ______

______Signature Title Date

Print Name: ______

Conditions 1. In the event that the funds are not used for the purpose as described in the application, or if there are misrepresentations in the application, the full amount of the financial assistance will be payable forthwith to the City. 2. If there are any significant changes in the funding of the program or service from that contemplated in the application, the City will be notified of such changes through the Office of the Managing Director of Social Policy forthwith. 3. The Organization will make or continue to make attempts to secure funding from other sources as indicated in its application. 4. The Organization will keep proper books of accounts of all receipts and expenditures relating to the program or service as described in the application. 5. The Organization will make available for inspection by the City or its auditors all records and books of accounts of the Organization upon request from the City. 6. If the program or service proposed in the Organization’s application has not commenced, or is not completed and there remain City funds on hand, or is completed without requiring the full use of the City funds, such City funds will be returned to the City through the Office of the Director of Finance. 7. The program or service may not be represented as a City program, and the Organization does not have the authority to hold itself out as an agency of the City in any way; the only relationship being that the City has approved and granted financial assistance to the Organization.

Please note: Once you submit your application and supporting attachments, they become public documents. Information provided may be used for statistical reporting purpose. Incomplete applications will not be considered. The City reserves the right to apply other evaluation criteria as it deems relevant. APPLICATION DEADLINE IS 4:30 PM FRIDAY, MAY 12, 2017 (Please remember to submit the completed application and all required documentation)

ALL required materials (hard copies and digital) must be received by the City no later than the deadline.