Please designate which grant type you will be applying for One Year Small Grant Award(maximum award $30,000) Two Year Large Grant Award (maximum award $100,000) I. Organization Information Organization Name (applicant) Is this organization the fiscal agent Yes No If No, fiscal agent name Fiscal agent Tax ID # Is the fiscal agent a 501(c)3 organization? Yes No 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: Exercise/fitness Health education Nutrition/diet program Healthy lifestyle/living Social cohesion/connectivity Other 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): Adair Park Ashview Heights Capitol View Capitol View Manor Harris Chiles Hunter Hills Just Us Mozley Park Oakland City Washington Park West End Westview Please tell us how you will document and monitor that 75% of program participants reside in one of 12 Westside Impact communities listed above: V. Project Summary The Atlanta BeltLine Westside Trail short-term outcomes are shown below: Increase use of the Westside Trail. 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. Increase physical activity levels of program participants. 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. Improve program participant’s perceptions about using the Westside Trail, specifically around areas that promote their use and decrease barriers to use. 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. Please describe the overall project goal, how this goal aligns with the mission of your organization and the need for this project in the community (remember, relate the project need to the Atlanta BeltLine Westside Trail) (250 word limit): Words left: 250 Please describe your preliminary plan for evaluating the impact of one or more of the above short-term outcomes. (250 word limit): Words left: 250 Please describe how your organization has a preliminary and thoughtful plan for the project’s continued operation after grant funding ends (250 word limit): Words left: 250 Please indicate and describe any potential or current partnerships/collaborations with other community organizations that may promote greater program reach and diversity across the Westside Trail neighborhoods (250 word limit): Words left: 250 VI. Target Population Please describe the target population to be served by the proposed project (250 word limit): Words left: 250 Please provide any other information relevant to your program (250 word limit): 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.