Grant Application Form

Grant Applications must be received by the Town on or before March 1st of each year

Basic Information

For what type of grant are you applying?

Category: [ ] Specific Project [ ] Special Event [x] Program (annual operations)

Project / Event / Program Name & Description: Crossing guard required at intersection of Craigflower and Admirals

Grant amount applied for? $ __________ % of project/event/program budget __________ %

Date the project, activity, event or program will occur: __________

Has your organization ever received grant funding from the Town? [x] Yes [ ] No* SD61 * 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? [ ] Yes [x] No * If yes, in what year(s)? __________

Does your organization issue grants to other organizations? [ ] Yes [x] No * 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

Resolution of Board of Directors to request a Grant in Aid from the Town of View Royal. (Note: N/A written in margin) ** 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.
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: Shoreline Middle School Mailing Address: 2750 Shoreline Dr. VICT. BC V9B 1M6 Operating at: 2750 Shoreline Dr.

Ph: 250 388 8367 Fax: 250 361 2630 Email: jadamson@sd61.bc.ca Contact: Jennifer Adamson Title: Principal

Society Registration Number: __________ Year Registered: __________ (Note: N/A written in margin) Charity Registration Number: __________ Year Registered: __________ Year Founded: __________ Fiscal year end: __________ (day) / __________ (month)

List any other geographic areas in which your organization operates: __________

Your Organization’s Personnel

1) Organization Executive and Staff: President: Principal: J. Adamson Telephone: 250 386 8367 Secretary/Treasurer: __________ Telephone: __________ Board Members: (Note: N/A written in margin)

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

Name and Position	Paid	Volunteer

Your Organization’s Objectives and Services

1) Describe your organization's mission statement and how your services meet them: SD61: To nurture each student's learning and well being in a safe, responsive and inclusive learning community.

Your Proposed Program Budget

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

(Note: The following tables in the original document are crossed out with a diagonal line)

A. Income

Item	Last Fiscal Year (If program was in existence)	This Fiscal Year (Proposed program budget)
Town of View Royal
Fees or Membership Dues
Government Revenue (specify below)
Interest income
Bingo revenues
Direct access revenues
Fundraising projects
Other Revenue (specify below)
TOTAL INCOME

B. Expenses

Item	Last Fiscal Year	This Fiscal Year
Administration
Wages/Honouraria/Benefits
Supplies and Equipment
Major Capital Costs
Mortgage/Rent/Utilities
Fees (licensing, etc.)
Insurance
Advertising/Printing/etc.
Other (specify below)
TOTAL EXPENSES

Details of Your Organization’s Grant Request

1) Nature and goals of the project, program or event: Shoreline Middle School and Craigflower Elementary School are in need of a crossing guard (position) to ensure safe commuting, walking, traveling across the intersection of Craigflower and Admirals to attend school.

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

road safety
student safety
school attendance
parent satisfaction

Conditions of Funding

The applicant must acknowledge the support of the Town in all printed and publicity material related to the project, event, or program;
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.
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.
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.
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.
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: Jennifer Adamson Title: Principal Date: Nov. 12/2018

Grant Application Form - Attachment 2