Application Number (for HUGS II Use Only) ___________
Application Must Be Typed
APPLICANT INFORMATION
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Applicant's Name
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Contact Person
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Contact Phone
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Mailing Address
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City/State/Zip
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Applicant E-Mail Address
PROGRAM INFORMATION
Program Title_____________________________________________
Amount Requested from HUGS II ____________
Program Date(s), Time & Place
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1. Program Description: Summarize the proposed violence prevention/safety program in the space provided. (Describe the target audience; what will happen; where it will occur; and how the program will be accomplished. NOTE: You may provide additional narrative information on a separate sheet of paper, but summarize the project here.)
2. How would funding impact this program?
3. Explain how this violence prevention/safety program will reach and benefit the community. How will you know it is successful? (Include promotion and plans for evaluation.)
4. Describe your plans for promoting the program to your target audience.
5. Please detail the qualifications of key presenter(s), actor(s), or organizations involved with leading the program.
BUDGET INFORMATION
Total Program Cost $_________________
Matching Funds $_________________
Itemized Program Expenses
Presenter(s), Actor(s) Fees $_______________
Program Supplies $_______________
Printing $_______________
Other $_______________ Describe:
Authorized Signature: The signature below is that of the person authorized to testify as to the accuracy of this application and the person who agrees that the required acknowledgment will be given to HUGS II if this application is approved.
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Signature Title Date
$_________________
Amount Approved
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Signature of HUGS II President or Authorized HUGS II Member (Title)
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Date