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CHILD SEXUAL ABUSE AND EXPLOITATION PREVENTION BOARDChild Victims’ Trust FundRegional Prevention Grant ApplicationFiscal Year 2022The Board reserves the right to deem ineligible for further review any application that is incomplete or does not STRICTLY adhere to the instructions contained in this document.The Board has exclusive authority to approve or deny all grant applications. All awards are subject to the availability of funds.Applicants will not receive funding if the match requirements are not anization InformationOrganization Name FORMTEXT ?????Mailing Address FORMTEXT ?????City State ZIP Code FORMTEXT ?????Phone Number FORMTEXT ?????Fax FORMTEXT ?????Agency Website FORMTEXT ?????Federal Employer I. D. FORMTEXT ?????KY Secretary of State Organization I.D. FORMTEXT ?????Counties and Cities Served by Agency FORMTEXT ?????Primary Contact InformationContact Name FORMTEXT ?????Title FORMTEXT ?????Email Address FORMTEXT ?????Direct Phone Number FORMTEXT ?????Funding InformationProgram Title FORMTEXT ?????Total Amount Requested from CVTF FORMTEXT ?????CVTF Funding HistoryNumber of Years Funded FORMTEXT ?????Last Year Funded FORMTEXT ?????Amount Funded FORMTEXT ?????Previously Funded Program Title FORMTEXT ?????Agency Name (if changed) FORMTEXT ?????Financial Assistance DataDoes the potential grantee have any:Outstanding liens or court judgments?Yes FORMCHECKBOX No FORMCHECKBOX Explain if your response to the question is ‘yes’ FORMTEXT ?????Back payments owed to IRS or KY Department of Revenue.Yes FORMCHECKBOX No FORMCHECKBOX Explain if your response to the question is ‘yes’ FORMTEXT ?????Current or previous civil actions?Yes FORMCHECKBOX No FORMCHECKBOX Explain if your response to the question is ‘yes’ FORMTEXT ?????Criminal Background ChecksHas the agency obtained KSP criminal background or AOC record checks on paid staff within the past 2 years?Yes FORMCHECKBOX No FORMCHECKBOX Has the agency obtained KSP criminal background or AOC record checks on independent contractors within the past 2 years?Yes FORMCHECKBOX No FORMCHECKBOX Has the agency obtained KSP criminal background or AOC record checks on volunteers within the past 2 years?Yes FORMCHECKBOX No FORMCHECKBOX Program Summary FORMTEXT ?????Program Impact Regional Impact: FORMTEXT ?????Service Area: FORMTEXT ?????CVTF Promotion Plan FORMTEXT ?????Form 1. GRANT APPLICATION CHECKLISTCheck all that apply and/or are attached: FORMCHECKBOX Grant Application Checklist FORMCHECKBOX CVTF Regional Prevention Grant Application FORMCHECKBOX Statement of Cooperation and Assurances FORMCHECKBOX Application Narrative FORMCHECKBOX Anticipated Program Revenue Detail—Breakdown by Source Form FORMCHECKBOX Budget Plan FORMCHECKBOX Budget NarrativeRequired Attachments: FORMCHECKBOX Evidence of 501(c)(3) or other non-profit/public status (e.g. IRS determination letter) FORMCHECKBOX List of Current Board Members with affiliations FORMCHECKBOX Agency Staffing Chart or other Personnel Diagram FORMCHECKBOX Agency Audit FORMCHECKBOX Year-end Financial Statements FORMCHECKBOX CV/Resume of Agency director FORMCHECKBOX Job descriptions and qualifications for each position involved in the proposed child sexual abuse prevention program FORMCHECKBOX Letters from collaborative partners on partner’s letterhead FORMCHECKBOX Agreements for consultant and contractual services on vendor’s letterhead FORMCHECKBOX Equipment price quote(s) on vendor’s letterhead FORMCHECKBOX Materials price quote(s) on vendor’s letterhead FORMCHECKBOX Program curriculum being proposed FORMCHECKBOX Evaluation instrument(s) or tool(s) FORMCHECKBOX Agency/Program publications (e.g. brochure, newsletter, Web page, etc.)Application Format (unless otherwise noted in the Guidelines, Overview & Instructions): FORMCHECKBOX White, 8 ?” by 11” paper FORMCHECKBOX Typed, double-spaced, single-sided FORMCHECKBOX Type is not all bold FORMCHECKBOX Type is not all capitalization FORMCHECKBOX Type is not all italics FORMCHECKBOX Page headers reflect agency name on ALL pages FORMCHECKBOX The Application Narrative does not exceed 12 pages in length. The Budget Narrative does not exceed 6 pages in length. Anything beyond the page limit will not be considered by the Board. Form 2. STATEMENT OF COOPERATION AND ASSURANCESThe Grantee represented by the undersigned, hereby states and assures the following:1.I have read and understand the Child Victims’ Trust Fund Prevention Grant Application Guidelines, Overview & Instructions (including the eligibility and funding rules, and applicant/grantee responsibilities) and agree to administer the Program in a manner consistent with the Prevention Grant requirements. 2.The Grantee agency and I will comply with all state regulations, policies, guidelines and requirements related to the use, application and acceptance, and reporting of state funds for this state-assisted program. I further assure that the Grantee agency will provide full access to agency documentation, records and other pertinent information as deemed necessary by the CSAEP Board or its staff, the Finance and Administration Cabinet, the Auditor of Public Accounts, or the Legislative Research Commission, as required by KRS 61.878(1)(c), for monitoring purposes.3.The Grantee agency and I are both in compliance with all policies and regulations of our governing Board, all state and federal laws, including but not limited to child abuse reporting laws, and the grant requirements of any additional state or federal grants received by the Grantee agency. 4.The Grantee agency does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or the provision of services, and provides, upon request, reasonable accommodation necessary to afford individuals with disabilities an equal opportunity to participate in all programs and activities. 5. The Grantee agency will ensure that a KSP background check or AOC record check (no older than two years) and are completed before initiation of the Prevention Program. The background checks are required for each person with access to or participating in the administration of the Prevention Program. The Background Verification Form will be provided with the contract if the grant is awarded. Applicants shall report any background check returned with anything other than minor traffic offenses to the CVTF Program Administrator for further review. Failure to report any such substantiation or convictions may result in the discontinuation of funding.6. The Grantee agency and I shall display the CVTF logo and statement crediting CVTF funding on all published Grantee materials. The CVTF logo will be included on all of the Grantee agency’s printed materials referencing a CVTF program, such as brochures or agency websites. In addition to the CVTF logo, all materials discussing the Grantee Agency’s CVTF Program shall include the following statement: “This publication/program is funded in part by a grant from the Child Victims’ Trust Fund.”The information contained in this application is, to the best of my knowledge and ability, true and accurate.Signature of Person Responsible for Administration of the Regional Prevention Program:Name and Title (typed) FORMTEXT ?????SignatureDate (typed) FORMTEXT ?????Signature of Grantee Agency Executive Director or Board Chair:Name and Title (typed) FORMTEXT ?????SignatureDate (typed) FORMTEXT ?????APPLICATION NARRATIVEAgency DescriptionMission Statement or Purpose FORMTEXT ?????Brief Summary of the Agency’s History FORMTEXT ?????Brief Summary Other Child Sexual Abuse Prevention Programs Offered by the Agency FORMTEXT ?????Community DescriptionGeography FORMTEXT ?????Demographics FORMTEXT ?????Data Source and the Year the Data was Collected: FORMTEXT ?????Ethnic, Racial and Cultural Characteristics FORMTEXT ?????Data Source and the Year the Data was Collected: FORMTEXT ?????Resources FORMTEXT ?????Coordination with Other Agencies, Groups and Professionals FORMTEXT ?????Prevention Program DescriptionProgram Description FORMTEXT ?????Consistency with Prevention ApproachPrevention Approach: FORMCHECKBOX Primary FORMCHECKBOX Secondary FORMCHECKBOX TertiaryExplanation: FORMTEXT ?????Program Rationale and Gaps in Services FORMTEXT ?????Program Innovation FORMTEXT ?????Program Goals and Objectives FORMTEXT ?????Target Population and Contributing Factors FORMTEXT ?????Access to the Target Population FORMTEXT ?????Risk, Protective and Vulnerability FactorsRisk Factors: FORMTEXT ?????Protective Factors: FORMTEXT ?????Vulnerability Factors: FORMTEXT ?????Qualifiers FORMTEXT ?????Data Source and the Year the Data was Collected: FORMTEXT ?????Meeting the Needs of the Target Population FORMTEXT ?????Prevention of Child Sexual Abuse in the Target Population FORMTEXT ?????Program CurriculumContent FORMTEXT ?????Learning Goals and Objectives FORMTEXT ?????Consistency with Current Research, Literature and Best Practices FORMTEXT ?????Data Source and the Year the Data was Collected: FORMTEXT ?????Appropriateness for Target Population FORMTEXT ?????Sensitivity to Multicultural Audiences FORMTEXT ?????Program DeliveryProposed or Secured Location(s)/ Venue(s) FORMTEXT ?????Number of Targeted Recipients FORMTEXT ?????Number and Duration of Exposures FORMTEXT ?????Interactive Formats FORMTEXT ?????Parent Components FORMTEXT ?????Internet Components FORMTEXT ?????Barriers and Approaches to Overcoming Them FORMTEXT ?????Available ResourcesStaff, Independent Contractors and Volunteers Responsible for Program Implementation FORMTEXT ?????Paid Staff Positions FORMTEXT ?????Independent Contractors and Volunteers FORMTEXT ?????Supervision of Staff, Volunteers and Consultants FORMTEXT ?????Staff, Volunteer and Consultant Training FORMTEXT ?????Training of Other Involved Parties FORMTEXT ?????Collaboration and Coordination Efforts with Other Agencies and Groups FORMTEXT ?????Implementation Timetable FORMTEXT ?????Evaluation Plan -- State your objectives in quantifiable terms. State your objectives as outcomes, not process. Objectives should specify the result of an activity. Objectives should identify the target audience or community that you plan to serve. Objectives need to be realistic and something you can accomplish within the grant period.Evaluation of Program Goals and Objectives FORMTEXT ?????Evaluation of Learning Goals and Objectives FORMTEXT ?????Determination of Success FORMTEXT ?????Evaluation Instrument(s), Tool(s) and/or Other Assessment Methods of Each Objective and Goal FORMTEXT ?????Evaluation/Assessment Timeframes FORMTEXT ?????Program Modifications, Enhancements or Improvements FORMTEXT ?????CVTF Promotion PlanCVTF Logo, Income Tax Refund Check-Off and “I Care About Kids” License Plate and CVTF Funding Statement in Published Materials FORMTEXT ?????Distribution of CVTF Posters and Brochures FORMTEXT ?????Plan to promote the CVTF in publication and/or social media FORMTEXT ?????PROGRAM BUDGETForm 3. Anticipated Program Revenue Detail —Breakdown by Source FormSourceCommitted or Potential FundingSub-Total AmountCVTF GrantPotential FORMTEXT ?????Cash Match*(minimum 10% of total CVTF Grant request) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????In-kind Match* FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????GRAND TOTAL (all sources of anticipated program revenue) FORMTEXT ?????* Pursuant to KRS 15.935(1) (a) 2 and KRS 15.940 (4), a 50% match is required. The match composition shall be as follows: The Cash match (i.e. other funding sources, cash donations, grants, salaries paid through agency sources, etc.) shall total at least 10% of the total CVTF grant amount. This sum shall be subtracted from the total match amount. The remainder of the match requirement may be met through cash and/or in-kind match (i.e. donated facilities, goods or services, volunteer services, etc.). The type of contributions stipulated as cash and in-kind must be directly related to the program being funded and shall be subject to approval of the Board, and the applicant shall maintain documentation for such contributions. Form 4. Budget PlanName of Agency: FORMTEXT ?????Name of Program: FORMTEXT ?????Budget Period: From (mm/dd/yy) FORMTEXT ?????To (mm/dd/yy) FORMTEXT ????? ANTICIPATED PROGRAM REVENUE: $ FORMTEXT ?????CVTF Grant (column A) $ FORMTEXT ?????Total Match (columns B and C) $ FORMTEXT ?????2. PROGRAM BUDGET:Funding SourcesCost CategoryCVTF Grant(Column A)Cash Match(Column B)In-Kind Match(Column C)SUB-TOTALS(Column D)a) Staff Salaries FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????b) Staff Fringe Benefits FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????c) Consultant/Contractual Services FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????d) Training & Travel FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????e) Operational Expenses FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????f) Equipment FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????g) Materials FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????GRAND TOTALS$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????BUDGET NARRATIVECost CategoriesStaff SalariesJustifications and Mathematical Calculations for Staff: FORMTEXT ?????Need for CVTF Funding: FORMTEXT ?????Lack of Alternative Funding Sources: FORMTEXT ?????Justifications and Mathematical Calculations for Volunteers: FORMTEXT ?????Fringe BenefitsComponents: FORMTEXT ?????Justifications and Mathematical Calculations: FORMTEXT ?????Need for CVTF Funding: FORMTEXT ?????Lack of Alternative Funding Sources: FORMTEXT ?????Consultant and Contractual Services FORMTEXT ?????Training and Travel FORMTEXT ?????Operational Expenses FORMTEXT ?????EquipmentJustifications and Mathematical Calculations: FORMTEXT ?????Need for CVTF Funding: FORMTEXT ?????Lack of Alternative Funding Sources: FORMTEXT ?????Materials FORMTEXT ?????Diversification of Funding FORMTEXT ????? Reduced CVTF Funding FORMTEXT ????? ................
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