Youth Violence Mini Grant Application for Prevention, Intervention & Re-Entry Programs

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Agency Information and Program Narrative

Email *

Agency/ Organization Name *

Agency Address *

Agency Phone # *

Agency Alternate Phone #

Agency email address *

Agency website address; if none, enter "none" *

Agency CEO/ Director *

Proposed Program Name *

Program Manager *

Program Manager Phone # (list best contact #) *

Program Type: *

Prevention

Intervention

Re-Entry

Total Amount Requested (cannot exceed $10,000 and should match the total on the budget form to be submitted separately) *

Organization Commitment & Capacity (20 points) Please provide a brief (maximum 250 word) narrative which describes the organization's experience and capacity to successfully offer youth violence prevention, intervention or re-entry services. Include collaborative relationships with other organizations and whether those collaborations will contribute to this program. NOTE: if you have the narrative prepared, you can copy and paste it into this form! *

Program Description (30 points) Please provide a detailed 250-500 word narrative which describes the program for which this funding is requested. After the narrative, you will be asked to enter specific information about program clients and logistics. NOTE: if you have the narrative prepared, you can copy and paste it into this form! *

Where will the program be held? *

Are you planning to use a Hampton Community or Neighborhood Center? If you answer yes, please download, complete, and submit the "Facility Intent to Use Form" available on the website. *

Yes, we will use a Community/Neighborhood Center and will submit the appropriate form

No, we will not be using a Community/Neighborhood Center

Will transportation be provided? *

Yes

What age group(s) will be served in the program? *

10-13 year olds

14-17 year olds

18-24 year olds

Age is not a factor in program recruitment

Required

What gender will be served in the program? *

Both females and males

Females only

Males only

List any other specific criteria for participants: *

How many total participants will be served in the program? (enter a number) *

How will participants be recruited? *

Approximately how many hours will participants spend in program activities each week? (enter a number) *

For how many weeks will the program run? (enter a number) *

What plan do you have to implement the program if we continue to face restrictions based on the COVID19 pandemic?

Please share any additional information on the program, its participants, and recruitment.

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms