LeadingAge Minnesota



ACT on Alzheimer’s Action Communities2016 Competitive GrantsJuly 14, 2016GRANT APPLICATION FORMThe 2016 Application Form (dated July 14), Workplan, Budget and Letters of Commitment must be received on or before 5:00 p.m. on September 1, 2016. Please read the ACT Action Communities Request for Applications prior to completing this form.Please submit this Application Form as a Word formatted document using a minimum font size of 11 point. Relevant attachments will be accepted, but are not required, with the exception of the Letters of Commitment outlined in the Eligible Applicants section of the Request for Applications. E-mail submissions are preferred; other options include mailing or faxing. All submissions must be received in our office on or before 5:00 p.m. on September 1, 2016. Send to:Leanna SmithMetropolitan Area Agency on Aging2365 McKnight RoadN. St. Paul, MN 55109Fax: 651-641-8618lsmith@Questions about the application should be submitted by e-mail to Leanna Smith at: lsmith@.APPLICANT INFORMATION AND SUBMISSIONApplicant/Fiscal Agent:Name and description of community in the project (e.g., name of city or multiple cities):Indicate that you have consulted the technical assistance organizations noted below: Consulted the following Area Agency on Aging staff (insert staff name): Consulted the Alzheimer’s Association Minnesota North Dakota staff (insert staff name):Project Lead Name and Title:Mailing Address:Telephone:Fax Number:Email Address:Contact information and signature of the person authorized to submit the application for funding and commit the applicant organization to completing the work plan and budget:Name and Title:Organization:Mailing Address:Telephone:Email Address:_______________________________________________________________Signature of Authorized ApplicantDatePROJECT NARRATIVEThe narrative description should not exceed 3 single-spaced typed pages in a minimum font size of 11 point, with 1-inch margins. Up to 10 points per question (30 points total) will be awarded for responses to the questions below.1. Summarize your community’s dementia friendly/dementia capable work completed to date, including involvement in local, regional or other initiatives. If your community is currently using the ACT on Alzheimer’s? Toolkit and community engagement process, please indicate the Phase (Convene, Assess, Analyze) of work underway and describe the activities. 2. Describe how using the ACT on Alzheimer’s? Dementia Friendly Communities Toolkit and process has or will advance your community toward being dementia friendly.3. In the table below, identify influencers/champions and project partners, indicate their community sector and outline their role on the Action Team. (Review the Convene Phase resources for guidance on building your action team .) Indicate whether they are already committed or being recruited. Attach Letters of Commitment from at least three partners representing different community sectors. The letter should outline their role and commitment to participate through the end of the project.NameOrganization/AffiliationCommunity SectorRole on Action TeamCommitted or RecruitedPROJECT WORKPLANComplete the following workplan by describing the objectives your Action Team will achieve in each toolkit phase, the detail of the steps to reach each objective, the person(s) or title(s) of those who will be responsible, and target dates for completion. To allow adequate time for the implementation of Phase 4 activities, work activities for Phases 1, 2 and 3 must be completed by no later than June 1, 2017. An Action Community Workplan template can be found at: under Step 4.This workplan will be awarded a maximum of 10 points.ACT on Alzheimer'sAction Community WorkplanObjectiveSteps to CompletePerson or Title Responsible, Organizational Affiliation, if anyTarget Dates for Comple-tionToolkit Phase(Indicate 1,2, 3 or N/A)For example: Prepare to assess Hold an interview training sessionConduct interview training with volunteersAssign volunteers to interviewees Review pre-interview email, call script and materials for intervieweesAssemble resource packets to distribute while doing interviews Community CoordinatorCommunity Assessment Team2PROJECT BUDGETProvide a basic numerical budget demonstrating the need for funds requested to implement your workplan. Complete only those categories relevant to your project and provide any additional information you feel necessary in the budget narrative. The numerical budget and budget narrative combined will be awarded a maximum of 10 points. ACT on Alzheimer'sProposed Project BudgetExpense CategoryDescriptionACT on Alzheimer’s Grant FundsPersonnelContractualServicesIn-state TravelLearning SummitPhotocopies, Printing, PostageSuppliesCommunications/PromotionMisc./OtherGRANDTOTALBUDGET NARRATIVE (limit to 1 page using a minimum font size of 11 point) ................
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