HEALTHY VALLEY 2000

HEALTHY VALLEY PROJECT

MINI-GRANTS PROGRAM FOR TEACHERS & ADMINISTRATORS

2002-2003 A P P L I C A T I O N F O R M

INSTRUCTIONS This form is a printable application. You may print out this application and then type in your information. Please use only the space provided.

Please describe the project as clearly and specifically as possible

_____________________________________________________________________________________________

What need does the project fulfill?

_____________________________________________________________________________________________

How will this project enhance and enrich student learning?

_____________________________________________________________________________________________

How will you involve parents in this project?

_____________________________________________________________________________________________

How will you involve community groups, organizations, businesses or individuals in this project?

_____________________________________________________________________________________________

What are your goals for this project, i.e., what will be the impact or result of this project? (Please be as specific as possible)

_____________________________________________________________________________________________

How will you judge the success of this project? (Please be as specific as possible)

_____________________________________________________________________________________________

Please detail your budget requests. Please be specific and clear, and do not exceed $500.

Materials / Equipment / Services Amount

___________________________________________________________________ $____________________

Please list any other funds you have received for this project, or any other grant applications you have pending for this project

_____________________________________________________________________________________________

Personal Information. Please complete ALL the information below.

Contact Person _________________________ Title/Position _______________________________

Grade Level ________________________ Number of Students ____________________________

School Name _____________________________________________________________________

School Address ___________________________________________________________________

School Phone ___________________________Home Phone _____________________________

Home Address _____________________________________________________________________________

Project Title _______________________________________________________________________________

DATE ________________________ SIGNATURE OF APPLICANT _____________________________________

DATE ________________________ SIGNATURE OF SCHOOL PRINCIPAL _____________________________

Please mail this application to: Healthy Valley Project, P.O. Box 418, Ansonia, CT 06401

OR Fax this application to: (203) 732-8831

DEADLINE FOR SUBMISSION OF APPLICATIONS IS NOVEMBER 1, 2002.

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