Programs

Recreational Activities Assistance Program

Formulaire d'inscription

Final date to apply: August 16th 2007

Warning: This webform is intended for direct printing from your browser ONLY. You will still have to send the printed form with necessary documents by regular mail (where to send it?).

I. Name and address of organization (official name according to registration certificate), along with name of president

Organization :
Address :
City :	Postal code:
Phone :	Fax :
E-mail :
Name of president :

II. Name and address of person in charge of project (contact person)

Person in charge of project:
Address:
Phone (work):	Phone (home):

III. Accompanying documentation (mandatory)

Photocopy of registration certificate:	Yes No
Evaluation report (only for organizations that received financial assistance through the program in 2006-2007):	Yes No Previously submitted
Information brochure:	Yes No

IV. Project Information

Project title:

Description:

Type of disability (indicate the number of participants for each disability group):
Motor		Intellectual
Autistic		Psychiatric
Auditory		Visual
Multiple disabilities (please specify)

Age group of participants (indicate the number of participants for each age group):
0 - 6 years		7 - 12 years
13 - 17 years		18 - 35 years
36 - 54 years		55 and over

Total number of participants:

Total hours for activity (combined):

Activity site:

Activity schedule:

Total hours for activity (per participant):

Number of staff overseeing activity:

V. Budget

Summary of budget estimates*
Estimated revenues	Estimated expenses
Recreational Activities Assistance Program $	Staff wages $
Participant registration $	Rental fees $
Organizational funds $	Transportation $
Partner organizations (please specify) $	Miscellaneous $
Other (please specify) $
Total $	Total $

VI. Additional information

1- How will this new project allow persons living with a disability to explore and develop new interests related to leisure activity?

2- How did you identify this new need? (How does this project differ from your current activities?)

3- How does this project encourage partnership and collaboration with other community organizations, such as leisure organizations, municipal recreational services, businesses, CLSC’s, schools, etc.? (please specify names of partner organizations)

4- How do you intend to promote this project? (articles in publications, information campaign targeting the population at large or specific organizations, etc.)

5- Are the types of activities proposed in your project offered by other organizations in Montreal? If so, how do your activities differ from these, or how do they complement them?

6- Briefly explain why you feel the amount of financial assistance you are applying for is necessary (re: allocation of funds).

7- Additional information (if applicable).

We attest that the information provided above is correct. In the event that we

                  receive financial assistance through this program, we commit to using the funds as

                  specified in this agreement and to respect the program requirements as specified by AlterGo.

Name:

Position of authorized person:

Date:

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*: The submitted budget must be balanced. Requested financial assistance must not exceed 75% of the total cost of the project.