Statewide Health Improvement Program Cottonwood, Jackson, Faribault, Martin & Watonwan Counties

CJFMW SHIP MINI-GRANT APPLICATION: COMMUNITY NUTRITION APPLICANT INFORMATION Organization: Contact Person: Address: City: E-mail: County: Phone: STRATEGY SELECTION 1. Please indicate which strategy (ies) are you applying to work on? Increasing EBT access at Farmers Markets Starting a Farmers Market in a community, worksite, school or hospital. Offering nutrition information on menus (local restaurants) Processing local foods Developing marketing campaigns to promote locally grown foods and Farmers Markets Developing a directory of processors, growers, and rental spaces for processing Developing virtual Farmers Markets or CSAs places where people could go t Composting Increasing access to healthy foods through corner store initiatives. OTHER: Innovative Ideas that aim to increase consumption of healthy foods and increase access to those foods will be accepted 2. Please indicate which county or counties you selected strategies will impact. Cottonwood Jackson Faribault Martin Watonwan 3. How many people will be impacted? Identify the anticipated number reached. (Population of communities/neighborhoods impacted) and any supporting data (upcoming renovation projects). ZIP Code: Fax:

Statewide Health Improvement Program Cottonwood, Jackson, Faribault, Martin & Watonwan Counties
CJFMW SHIP MINI-GRANT APPLICATION: COMMUNITY NUTRITION INTEREST 1. Tell us why you are interested in receiving a mini-grant to work with the Statewide Health Improvement Program/ Food Policy Council.

BACKGROUND INFORMATION 1. Briefly discuss your organization and/or business. How long have you been in operation? What are the mission and goals of you organization?

2. If applicable, please provide an example of how you have worked collaboratively with other organizations or people to successfully plan or implement a project or program.

3. Please describe your capacity to successfully plan and/or implement the selected strategy. Include information on past work related to improving access to healthy foods or improving community nutrition.

4. Briefly describe the staff or people who will be working on this project. What are their backgrounds? What will their roles be in this project?

PROJECT DESCRIPTION 1. Provided a brief description of your project. What will you use the intended funds to do?

Statewide Health Improvement Program Cottonwood, Jackson, Faribault, Martin & Watonwan Counties
CJFMW SHIP MINI-GRANT APPLICATION: COMMUNITY NUTRITION

2. What do you hope to achieve by the end of the project?

3. How does your project incorporate policy (formal or informal) and/or environmental (changes to the physical environment to support healthy choices) changes?

4. How will you sustain the project beyond SHIP funding? 5. Please complete an action plan below for your project. Identify the deliverables (action steps) and associated milestones and well as an ESTIMATED completion date. An example has been provided in the first column. Add additional columns as you need. Project Action Plan Deliverables Associated Milestones Estimated Completion Date: Ex. Convene a task force of local growers to identify possible processing facilities in SC MN. Task force convened potential sites identified. September 2012

Statewide Health Improvement Program Cottonwood, Jackson, Faribault, Martin & Watonwan Counties

PROJECT BUDGET 1. Please provide a completed budget for your project. Budget Line Item Salary and Fringe Benefits Travel Supplies and Expenses Other Administrative Costs Total 2. Please provide a narrative of your budget items in the space below. Requested Grant Award Match (10% inkind/monetary)

SIGNATURES

Statewide Health Improvement Program Cottonwood, Jackson, Faribault, Martin & Watonwan Counties
I submit this mini-grant application to partner with the Statewide Health Improvement Program on behalf of the organization listed above. As the grant manager, I agree to fully participate in the assessment and evaluation process.

Including but not limited to: submitting data on time, providing organizational resources and staff to assist in the evaluation process when necessary, other as determined. Additionally, I will follow all SHIP guidelines for allowable uses of SHIP
dollars if awarded and will do so by seeking prior approval before accruing expenses. Signature of applicant:

Date: