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Health Partnership Form
Please designate which grant type you will be applying for
I. Organization Information
Organization Name (applicant)
Is this organization the fiscal agent
If No, fiscal agent name
Fiscal agent Tax ID #
Is the fiscal agent a 501(c)3 organization?
When was the fiscal agent established?
Address
City
State
Zip Code
Phone Number
Fax Number
Fiscal agent’s website
Enter 2015 Actual Organizational Revenue
II. Short Application Contact
Contact Name
Contact Phone Number
Contact Title
Contact Email
III. Project Information
Project Title

Project Type: (please check and specify the corresponding project type; applicants can check more than one type):Describe Briefly:

Project Start Date
Project End Date
Total Project Budget
Amount Requested
Proposed number of people to be directly served by this grant
IV. Communities Served
In order for the proposed program to be considered, at least 75% of program participants must reside in one of the 12 Westside Trail neighborhoods listed below (Please check all that apply):

V. Project Summary
The Atlanta BeltLine Westside Trail short-term outcomes are shown below:

  1. Increase use of the Westside Trail.
    1. Applicants should demonstrate measurable ways that the proposed programs will increase use of the Westside Trail. Strong applications will clearly outline the methods in which Westside Trail utilization will be recorded and evaluated.
  2. Increase physical activity levels of program participants.
    1. Applicants should clearly describe structured physical activity programming that will measurably improve physical activity levels among Westside Trail residents. Strong applications will provide clear performance targets and goals.
  3. Improve program participant’s perceptions about using the Westside Trail, specifically around areas that promote their use and decrease barriers to use.
    1. Applicants must clearly define baseline perceptions about the Westside Trail and outline a clear plan for measuring improved perceptions through the development and implementation of proposed programs. Strong applications will define the perceptions of interest and include measurement plans for both pre- and post-program implementation.

Words left: 250

Words left: 250

Words left: 250

Words left: 250
VI. Target Population

Words left: 250

Words left: 250
VII. Supporting Documents
One-page cover letter on organization’s letterhead describing the program, need for funding, goals and expected results
IRS 501(c)(3) letter (governmental entities: submit a letter from the CFO or CPA indicating exemption)
W-9 Form completed and signed (http://www.irs.gov/pub/irs-pdf/fw9.pdf)
Most recent strategic plan and executive summary
Most recent board-approved current year organizational budget, and previous year actuals
Most recent organizational financial audit
Most recent IRS Form 990 (governmental entities exempt)

Please click “Submit” only once.
Depending on the number and size of attachments you’ve included, the form could take up to 5 minutes to process.