Access4All Grant Application Form

Please note that this copy of the Access4All grant application form is for reference purposes

only. Please submit your online application at www.rickhansen.fluidreview.com. Only grant

application forms submitted online will be accepted.

SECTION I: BARRIER BUSTER PROJECT

Name of your Barrier Buster Project:

SECTION II: ORGANIZATION & CONTACT INFORMATION

A. Organization Contact Information The Recipient must be a Qualified Donee as defined by the Income Tax Act of Canada to be eligible

for the Barrier Buster Grant. If you are unsure, please see our FAQ for more information.

Organization Name

Is your organization a “Qualified Donee” as defined in the Income

Tax Act (Canada)? Yes

No

CRA Business Number

Street Address

City

Province/Territory Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and

Labrador

Northwest Territories

Nova Scotia

Nunavut

Ontario

Prince Edward Island

Quebec

Saskatchewan

Yukon

Country

Postal Code

Organization Website

B. Mission & Activities

What is the mission and purpose of your organization? What are its main

activities? (max 150 words)

C. Social Media

Provide information on all social media channels that your organization uses, if

any. Twitter Handle:

Facebook Page:

Instagram Profile:

YouTube Channel:

LinkedIn Page:

Other:

D. Applicant Information & Authorization

Complete contact details of the Applicant Full Name

Job Title:

Phone Number:

Alternative Phone Number:

Contact Email:

Preferred Language of Correspondence

English

French

Authorization of Applicant Please read carefully.

I, the Applicant understand and confirm that the approval of this application by

Rick Hansen Foundation (hereinafter “RHF”) and the award of a grant by RHF to

the Recipient will create a binding grant agreement between the Recipient and

RHF and I represent and warrant that I am duly authorized by the Recipient to

submit this application on behalf of the Recipient and to legally bind the

Recipient to such grant agreement. Further, if the Recipient is an

unincorporated association I represent and warrant that I am duly authorized by

the members of the Recipient to submit this application on their behalf and to

legally bind such members personally, jointly and severally to such grant

agreement.

I Agree

Name

Job Title

SECTION III: INFRASTRUCTURE IMPROVEMENT

A. Location

Where will the Infrastructure Improvement take place? Location Name

Street Address

City

Province/Territory Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Northwest Territories

Nova Scotia

Nunavut

Ontario

Prince Edward Island

Quebec

Saskatchewan

Yukon

Type of premise Select type of premise School

Park / Playground

Community Centre

Recreation Centre

Arts & Cultural Venue

Place of Worship

Other (please specify):

Other (please specify)

B. Timeline

Infrastructure Improvement proposed start date ____/__/__ (YYYY/MM/DD)

Infrastructure Improvement proposed end date End date must be before December 31, 2017 to be eligible.

____/__/__ (YYYY/MM/DD)

Are the start and end dates for your Infrastructure Improvement fixed or

flexible? Fixed/Flexible Fixed: The Infrastructure Improvement is only possible

between the start and end dates provided.

Flexible: The start and/or end dates of the

Infrastructure Improvement date is flexible.

Please explain how your start and

end dates are flexible.

C. Impact & Innovation

Describe the Infrastructure Improvement you propose to make to your

premises. Include how you have consulted people with disabilities (mobility,

vision, hearing challenges). (max 150 words)

Describe how the Infrastructure Improvement will make a difference for people

with disabilities. (max 150 words)

Describe how many people the Infrastructure Improvement will impact. (max

150 words)

Describe how the Infrastructure Improvement fosters innovation – if applicable

(creative, effective approach to accessibility solutions) and is sustainable. (max

150 words)

D. Partnerships & Engagement

Partnerships Will your organization be working with other organizations (e.g.,

community groups, people with disabilities, businesses, local governments,

and/or others) to deliver the Infrastructure Improvement?

Yes

No

If yes, please name the collaborating organizations and explain their roles.

Volunteers Will volunteers be involved to deliver the Infrastructure Improvement? Yes

No

How many volunteers do you anticipate participating, and in what

capacity?

How many volunteer hours do you expect to be expended?

Youth Involvement Will youth be involved to deliver the Infrastructure Improvement? Yes

No

If yes, please describe how youth will be involved.

Community Involvement How many community members do you expect to participate in the

Infrastructure Improvement?

Please provide any additional information on how the larger community

will be involved.

E. Expertise

Describe the skills, experience and/or expertise of your organization (and/or

collaborating partners) to implement the Infrastructure Improvement (max 150

words)

SECTION IV: AWARENESS EVENT This section seeks information about your Barrier Buster Project’s Awareness Event that will

celebrate the completion of the Infrastructure Improvement to your premises and raise awareness

within the community.

A. Location

Where will the Awareness Event take place? Same as Infrastructure Improvement site

Location Name

Street Address

City

Province/Territory

B. Timeline

Awareness Event proposed date Event must take place on or before January 31, 2018

____/__/__ (YYYY/MM/DD)

C. Awareness Event Reach and Impact

Describe the proposed Awareness Event, how it will showcase the Infrastructure

Improvement to the community and stakeholders, and the number of people

reached. (max 150 words)

Describe how your organization will generate media and public interest before,

during and after the Awareness Event (max 150 words)

Describe how your organization will engage government officials and other

notable guests at the Awareness Event (max 150 words)

D. Partnerships & Engagement

Partnerships Will your organization be working with other organizations (e.g.,

community groups, people with disabilities, businesses, local governments,

and/or others) to deliver the Awareness Event?

Yes

No

If yes, please name the collaborating organizations and explain their roles.

Volunteers Will volunteers by involved to deliver the Awareness Event? Yes

No

How many volunteers do you anticipate participating, and in what

capacity?

How many volunteer hours do you expect to be spent?

Youth Involvement Will youth be involved to deliver the Awareness Event? Yes

No

If yes, please describe how youth will be involved.

Community Involvement How many community members in total do you expect to participate in the

Awareness Event?

Please provide any additional information on community involvement, if

any

Official-Language Minority Community Involvement An Official Language Minority Community consists of Francophones who reside outside of Quebec,

or English-speaking residents of Quebec.

Will the Official-Language Minority Community be invited to attend the

Awareness Event? Yes

No

Will artists or performers of the Official-Language Minority Community be

invited to perform at the Awareness Event? Yes

No

Please describe how the Official-Language Minority Community will be

involved in the Awareness Event.

E. Expertise

Describe the skills, experience and/or expertise of your organization (and/or

collaborating partners) to deliver the Awareness Celebration Event. (max 150

words)

SECTION V: BUDGET & FUNDING SOURCES Please be sure to upload your budget. You can use the sample form provided.

Estimated Total Project Cost What is the budgeted cost of the Barrier Buster project? Inclusive of all taxes.

Infrastructure Improvement cost:

Awareness Event cost:

Total

Requested Barrier Buster grant amount Enter the Barrier Buster Grant requested amount.

Infrastructure Improvement (up to $20,000):

Awareness Event (up to $10,000):

TERMS & CONDITIONS

By submitting this application form, I acknowledge on the behalf of the Recipient, I agree to

the Terms and Conditions and have read the Privacy Policy of the Access4All Canada 150

Signature Initiative.

I consent to be contacted with further information about Rick Hansen Foundation.