1. What is the name of the activity?

2. What is the date of the activity?

3. Please provide specific details of the activity.

4. Who is involved in planning the activity?

5. Who is the activity designed for?

6. How many people do you hope to reach?

7. How is it related to Substance Abuse & Injury Prevention?

8. What is the message of your activity?

9. The SAP banner is provided for display at all activities.
What other Substance Abuse Prevention materials do you
plan to distribute and have avaliable (i.e. Pamphlets, posters)?

10. How much funding are you requesting?

11. Please provide a breakdown of expenses for which you are
requesting funding.

12. If your event is a moneymaking event, what happens to the profits?

13. Is this a one-time event or will it require ongoing funding?

14. What are others contrubuting to the project? (Include in-kind stuff/volunteer
time, hall & rental equipment, donations, use of own supplies & financial contributions)

15. What do you hope to achieve by hosting this activity?

16. Measuring the success of the activity is required. How are you going to
measure/evaluate the activity?

Follow-up reports are required. Please ensure that you submit the follow up report to
Hugh Dennis after your event, or make arrangements with Hugh to present the report
in person. You can contact him at 274-9827 ext. 229, or hdennis@nwhu.on.ca

Name of Contact Person:

Email Address:

Telephone Number of Contact Person:

Address of Sponsoring Agency: