Grant Application Form - Victoria Brain Injury Society

Basic Information

For what type of grant are you applying?

Category: Program (annual operations) [Checked]

Project / Event / Program Name & Description: Outreach Services for Brain Injury Survivors.

Grant amount applied for? $ 2,000 % of project/event/program budget 22 % Date the project, activity, event or program will occur: April, 2021 - Mar, 2022

Has your organization ever received grant funding from the Town? No [Checked]

• If yes, attach copies of printed material which acknowledged the financial support of the Town.

Has your organization received a permissive tax exemption from the Town? No [Checked]

• If yes, in what year(s)? _______________________________________________

Does your organization issue grants to other organizations? No [Checked]

• If yes, you must demonstrate that any funding provided by the Town will not be used to fund grants to other organizations and attach it to this grant application form.

Attachments Required

• [Checked] Resolution of Board of Directors to request a Grant in Aid from the Town of View Royal.
  • ** If there is no Board of Directors, a statement of request must be signed by the majority of the members of the non-profit or community organization.
• [Checked] Prior years financial statements of the organization.
• Documentation Town funding will not be used to fund grants to other organizations (if applicable)

About Your Organization

Legal Name of Organization: Victoria Brain Injury Society Mailing Address: Units C, D, & E - 830 Pembroke Street, Victoria, BC V8T 1H9 Operating at: Victoria Brain Injury Society (VBIS) Email: pamp@vbis.ca Contact: Pam Prewett Title: Executive Director Society Registration Number: S-0018491 Year Registered: 1983 Charity Registration Number: 122452121 RR0001 Year Registered: 2005 Year Founded: 1983 Fiscal year end: 31 / 03 (day / month)

List any other geographic areas in which your organization operates: Cobble Hill, Mill Bay, Malahat, Port Renfrew, Sooke, Southern Gulf Islands, Victoria, Saanich, Sidney, West Shore, Esquimalt

Your Organization’s Personnel

1) Organization Executive and Staff:

President: Wyatt Pickett Secretary/Treasurer: Trevor Jones

Board Members:

• Barbara Phillips
• Varun Dhaul
• Adam Harnden
• Natalie Benson
• Gerald Hartwig
• Tyler Dolan

2) List the staff or volunteer positions involved in carrying out the project:

Your Organization’s Objectives and Services

1) Describe your organization’s mission statement and how your services meet them: Please see attached

Your Proposed Program Budget

1) Please list all expenses and sources of project revenue, including “in-kind” contributions from your (or any other) organization.

Please see attached

Details of Your Organization’s Grant Request

1) Nature and goals of the project, program or event: Please see attached

2) Summary of direct and indirect benefits to the Town of View Royal: Please see attached

Conditions of Funding

1. The applicant must acknowledge the support of the Town in all printed and publicity material related to the project, event, or program;
2. Funds must be used for the purpose for which they were requested. Any funds not used for the requested purpose must be returned to the Town.
3. Funds will be released as follows: a. Grants in aid provided for annual programs will be released at 100% at time of approval by Council; b. Grants in aid provided for special projects or events will be released at 50% at time of approval by Council and 50% after receipt of the final report; c. Conditional grants in aid will be paid 100% upon satisfactory proof that the conditions, as set by Council, have been met.
4. Organizations receiving grants from the Town shall provide an accounting of the project or program for which the grant was approved as follows: a. Where the grant in aid was for a specific project or event the applicant must submit a final report within 45 days after the project or event is complete. b. Where the grant in aid was in support of an annual program, the applicant must submit a final report within 60 days of the end of the organization’s fiscal year.
5. An final report must include the following information: i. Evaluation of the project, event, or program; ii. Financial statement of actual revenue and expenses for the project, event or program; iii. Attendance figures, if applicable; iv. Number of participants in the project, event, or program; and v. Evaluation of the direct and indirect benefits to the Town.
6. In the event that the project or program is not completed, the grant recipient organization must notify the Town as soon as practical and refund any grant funds that have been provided for that project.

Your Directors’ Declaration

We, the undersigned, do hereby certify that this application and all appended forms and/or documents contain a full and accurate account of all matters stated:

Name: Wyatt Pickett Title: President Date: February 22, 2021

Name: Barbara Phillips Title: Secretary Date: February 22, 2021

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Please submit your completed application to: Town of View Royal 45 View Royal Ave Victoria, BC V9B 1A6 www.viewroyal.ca Fax 250-727-9551 email: finance@viewroyal.ca