Fillable Emergency Sexual Assault Response Services Grant Indigenous Services

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Emergency Sexual Assault Response Services Grant Indigenous Services

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Page 1 of 21
Please review the application guide before completing this form.
The guide can be found at: NEW Grant Program - Emergency Sexual Assault Response - Ending
Violence BC
A. APPLICANT INFORMATION
1. Contact Information
Project / Program Title:
Legal Name of Applicant
Agency
Mailing Address
(Street and Number)
Suite Number
City / Town / Village
Province
British Columbia
Postal Code
Physical Location (if
different from mailing
address)
Contact Person
Email
Phone
Fax
Alternate Contact
Email
Phone
Fax
Emergency Sexual Assault Response Services Grant
Indigenous Services Stream
Application Form
Page 2 of 21
2. Please indicate your organization type (applicants must be one of the following and
operate within what is now called British Columbia):
First Nations Band or Tribal Council (within British Columbia)
First Nations organization (incorporated as a not-for-profit society or registered charitable
organization) within British Columbia
Urban/off-reserve First Nation organization (e.g., Friendship Centres)
Métis service provider
Métis chartered community
3. Is your organization/agency (please indicate all that apply):
Currently providing sexual assault response services
Proposing to enhance your sexual assault response services
Proposing to implement new sexual assault response services
B. PROJECT CRITERIA
1. Provide a 250-word summary of your project including project name, project
objective(s), project services, project’s geographical area and groups to receive service.
Note: You will have an opportunity to elaborate on specific elements of your program in
the following questions. (Maximum 1,750 characters/250 words)
Page 3 of 21
2. Tell us about your organization’s experience.
a) Describe coordinated sexual assault response services and/or initiatives that your
organization currently delivers
b) If your organization does not currently deliver sexual assault response services
and/or initiatives, describe your organization’s experience delivering services to
victims/survivors or other vulnerable populations who have experienced sexual
assault and/or trauma related to historical sexual abuse.
c) If your organization does not currently deliver services that respond to sexual
assault, describe other relevant services your organization delivers (an example
might include trauma counselling).
(Maximum 3,500 characters/500 words)
Page 4 of 21
3. Describe your organization’s capacity to deliver an emergency sexual assault response
service.
Include a description of your organization’s capacity to serve diverse Indigenous
populations and communities. This may include information on working with survivors
who identify as 2SLGBTQQIA+, survivors who are sex workers, and/or survivors who
live with disabilities.
(Maximum 3,500 characters/500 words)
Page 5 of 21
4. Describe your organization’s readiness to deliver an emergency sexual assault
response service. (Maximum 3,500 characters/500 words)
Page 6 of 21
5. Describe your organization’s management structure including how staff are
supported/supervised. (Maximum 1,750 characters/250 words)
Page 7 of 21
6. Describe the communities/region the program will serve, and any unique considerations
(examples might include: specific community/population demographics, the existence of
work camps in the area, the rural or remote context of your community and/or lack of
particular services) and needs. (Maximum 3,500 characters/500 words)
Page 8 of 21
7. Describe the services that the program will provide, including how your program will
address the specific needs of the communities/region. (Maximum 3,500 characters/500
words)
Page 9 of 21
8. Describe:
• The community members that your program will be serving
• How your organization will provide services to intended community members
• How your organization will ensure accessibility to community members.
(Maximum 3,500 characters/500 words)
Page 10 of 21
9. Describe how your program will be responsive to the unique needs of Indigenous
communities and survivors of sexual assault in your region.
Please include a description of the culturally safe and culturally relevant supports that
will be part of your program. (Maximum 3,500 characters/500 words)
Page 11 of 21
10. Describe how the services will be structured to meet the needs of diverse Indigenous
sexual assault survivors in the region served by your organization (examples may
include survivors who identify as 2SLGBTQQIA+ survivors who live with disabilities,
and/or survivors working in sex work).
Please include a description of how your program will be designed to address barriers to
service that these communities may experience. (Maximum 3,500 characters/500
words)
Page 12 of 21
11. Describe the staffing, roles and duties that will be required to deliver the proposed
services under this funding. (Maximum 1,750 characters/250 words)
12. Describe any training that will be required for staff to deliver the proposed services. If
you have plans to address these training needs, please describe. (Maximum 1,750
characters/250 words)
Page 13 of 21
12. Describe the activities you will undertake, as well as timelines, to enhance services
and/or develop new services. Please use the table provided below and include the
following:
• planning, developing and implementing the services
• developing and preparing program materials
• staffing
• training
• program promotion
• engaging with the evaluator
• service delivery
• working with and/or establishing partnerships and/or relationships with other
agencies/committees
Activities
Timelines
Start Date
Page 14 of 21
Page 15 of 21
14. Describe how the services will be supported by other community agencies and relevant
police and health agencies, if applicable. Using the table below, please provide names
and contact information of agencies you are or will be working with on this project.
(Note: agencies that your organization currently works with may be contacted to confirm
their roles.)
Agency Name
Role (e.g., referral
source, Advisory
Committee member,
training partner)
Name and Contact
Information
Current or
Planned?
Current
Planned
Current
Planned
Current
Planned
Current
Planned
Current
Planned
Current
Planned
Current
Planned
Current
Planned
Current
Planned
Current
Planned
Page 16 of 21
14. Describe the key challenges that your program may face and how these challenges will
be addressed or managed.
Anticipated Challenges
Mitigation Strategies
Page 17 of 21
16. Describe your organization’s method of accounting for grant funding from this project.
(Maximum 1,750 characters/250 words)
Page 18 of 21
C. BUDGET INFORMATION
Proposals must contain a reasonable and detailed budget. Consideration will be given to the scope and reach of the project in
comparison to the amount of the budget (i.e., value for money). Please refer to the Application Guide for detailed instructions and
allowable expenditures.
PROJECT NAME:
Item / Description
Amount Requested
Year 1
(November 16, 2020 -
March 31, 2021)
Funding available:
$47,500 to $105,000
Amount Requested
Year 2
(April 1, 2021-
March 31, 2022)
Funding available:
$95,000 to $210,000
Year 3
April 1, 2022 -
March 31, 2023)
Funding available:
TOTAL
REQUESTED
In Kind $
and/or Funding
from Other
Sources
Per funding year
Staff (Include each staff member as a separate line item; note role; hourly rate; and total hours for each)
Program Staff (e.g., CBVS, Outreach)
Management Staff (e.g., Program Manager)
Consultants/Professional Fees/Honoraria
Staff participation in evaluation (over and
above frontline service delivery staff costs,
e.g. Supervisor, ED; up to a maximum of 4
%
of
overall budget per year)
Page 19 of 21
PROJECT NAME:
Item / Description
Amount Requested
Year 1
(November 16, 2020 -
March 31, 2021)
Funding available:
$47,500 to $105,000
Amount Requested
Year 2
(April 1, 2021-
March 31, 2022)
Funding available:
$95,000 to $210,000
Year 3
April 1, 2022 -
March 31, 2023)
Funding available:
TOTAL
REQUESTED
In Kind $
and/or Funding
from Other
Sources
Per funding year
Non-Staff
Materials/Supplies
Transportation
Equipment
Rent/Utilities
Page 20 of 21
PROJECT NAME:
Item / Description
Amount Requested
Year 1
(November 16, 2020 -
March 31, 2021)
Funding available:
$47,500 to $105,000
Amount Requested
Year 2
(April 1, 2021-
March 31, 2022)
Funding available:
$95,000 to $210,000
Year 3
April 1, 2022 -
March 31, 2023)
Funding available:
TOTAL
REQUESTED
In Kind $
and/or Funding
from Other
Sources
Per funding year
Training (if applicable)
Administrative Fees (not to exceed 15% of
total budget)
Other
TOTAL
Page 21 of 21
D. DECLARATION
To be signed by an authorized signatory of the sponsoring organization.
• The information contained in this application is accurate and complete.
• The application is made on behalf of the organization named with its full knowledge and
consent.
• The sponsoring organization is a registered legal entity in good standing.
I acknowledge that should my organization’s application be approved, I will be required to
participate in the evaluation process and submit regular reports on the activities and outcomes
described in this application, and on how the grant funds were spent.
Name of Authorized Representative:
Title:
Signature:
Date:
If application is approved, cheque should be made payable to:
___________________________________________
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Emergency Sexual Assault Response Services Grant Indigenous Services

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Completed 31 August 2020

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