Healthy, Safe & Strong Fund Form

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Identifying Data

Name of Person Authorized to Sign Agreement
Address
Contact Person

Activity Data Summary

Location of Activity

Proposal Information Summary

Submission Data

Have you applied to the Healthy, Safe & Strong Fund Application in the past for this activity event?
Have you received funding from the Healthy, Safe & Strong Fund in the past for this activity/event?

Detailed Activity/Event Information

Identify CSC Goals the activity/event will be addressing.
Are there other similar events, conferences or activities in Palm Beach County?

Budget

I. Expenses

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II. Source of Funding

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BUDGET AND REPORTING GUIDELINES

Explanation of Budget Page

I.    Expenses

Lines 1-4 refer to the cost of bringing in a presenter to provide training to the Palm Beach County professional community and volunteers who serve children and families.

Line 5 will show the cost of the space in which you are planning to hold the conference or training.

Line 6 refers to any refreshments that are to be served at your event.  Refreshments/meals must be covered by registration fees or sources other than CSC.

Line 7 provides for copies of handout materials for the participants at the event.  One set of the materials to be copied must be submitted to CSC.

Line 8 is for materials purchased to support the event.  Often these include workbooks, curricula, or video tapes. 

Line 9 asks for printing costs, and often involves the flyers, posters or other materials used to publicize the event.  CSC must be listed as a co-sponsor of the event and have its logo on materials.

Line 10 covers any mailing costs for the advertising of the event.  CSC requires postal receipts for the purchase of stamps or mailings.

Line 11 refers to supplies needed to hold the event.  These are to be consumable items such as folders, name tags, markers, flip chart pads, tape, paper, blank tapes, etc.  CSC will not cover any expense for items that would permanently supply your office (e.g., flip chart stands, tape recorders, staplers).

Line 12 is for items related to the event that don’t fit in any other category.  Often scholarships for participants who cannot afford the cost, editing of video tapes, or rental of microphones or other equipment is entered on this line.

If costs for any of the items are being covered by another agency or donor, the amount should be shown in the left column.  Under CSC’s column on the right, please reflect the amount you are requesting from CSC for that particular line item.

II.    Sources of Funding

Enter all revenue sources and associated funding in this section.

Receipts must be provided for all CSC funded line items.
CSC must approve funding for each event before any advertising or expense is reimbursed from the Healthy, Safe  and Strong Fund.