EmailMe Form - Loblaw Water Fund (OLD

Instructions:

Please refer to the Loblaw Water Fund Guidelines when filling out this form.

You may save / resume this form at anytime by scrolling to the bottom of the page and clicking "Save & Resume Later" button. Once clicked, a unique URL will be given. Please be sure to save this URL to be able to resume later.

Proposals will be received electronically until 5pm E.S.T. on December 18th, 2017. Proponents will be notified of the outcome of their proposal in March of 2018.

NOTE: Only proposals that are completed in full will be considered.

Successful proponents will have from April 1, 2018 until March 31, 2019 to complete projects and to report results to WWF-Canada.

Proponent Information

Proponent Organization *

Submitting Individual *

(Name and Title)

Signing Authority

(if different from above)

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Web Site

Phone *

### - ### - ####

Please provide a brief description of the proponent organization, including relevant conservation experience and proven achievements.

Has the proponent organization been a past recipient of a Loblaw Water Fund or other WWF grant?

Yes

No

If yes, state the type of grant, name of the project, and when it was received:

Proponent Type

Type of Organization

Registered Charity

Non-Profit Organization

Other Qualified Donee

Other Qualified Donees must be listed as a Qualified Donee on the CRA website at time of applying: http://www.cra-arc.gc.ca/chrts-gvng/qlfd-dns/qd-lstngs/menu-eng.html. Examples include First Nations, Municipalities, Universities, and Conservation Authorities.

Charitable Registration Number

(If applicable)

Business Number

(If applicable)

Project Type

Restoration

Monitoring

Check all that apply

For monitoring projects only, please describe how the data will be shared:

Monitoring projects must contribute data collected to an existing national/provincial/territorial/regional database and/or contribute to a long term monitoring effort.

Volunteer Engagement

How many volunteers do you estimate will be required for the completion of your project work?

If volunteers are needed for your project what types of activities would they be doing?

e.g. invasive species removal, planting native plants, collecting water samples, etc.

Would you like WWF's help in securing volunteers?

Yes

No

Project Title

Please provide a descriptive title of the proposed project. (15 Words Maximum)

Brief Project Summary

Briefly describe your proposed project.

This summary may be used in news announcements and communication materials regarding the fund.

What are the goals and objectives of the project? How will this project deliver on the Loblaw Water Fund objectives outlined in the Loblaw Water Fund Guidelines? Please clearly indicate which Watershed Reports health metric or threat indicator your project will address.

Project Location

Province / Territory

Name of Water body

Closest City or Town:

Watershed *

As per WWF's Watershed Reports http://watershedreports.wwf.ca

Sub-watershed *

As per WWF's Watershed Reports http://watershedreports.wwf.ca

Current State of Watershed

Please describe the current ecological state of this region and highlight any known threats.
Does the project site contain rare or unique features, such as any species at risk?
Please also provide the Health and Threats scores given to your sub-watershed as specified in WWF’s Watershed Reports (http://watershedreports.wwf.ca/)

Workplan

Set out the specific activities you will undertake to accomplish the stated objectives, deliverables and estimated timelines to complete the project by March 31, 2019.

Workplan

	Description of Activity	Deliverable(s)	Start Date	End Date
Activity 1
Activity 2
Activity 3
Activity 4
Activity 5
Activity 6
Activity 7
Activity 8
Activity 9
Activity 10

Who will do the work? Will you collaborate with other key stakeholders on this project?

How will you engage your local community?

How will you measure whether or not your project has been successful?

Communication of Results

How do you plan on communicating the results of your project?

Local Support

Please provide the names and contact information of at least two professionals in the conservation community who support this project.

	Contact Name	Organzation / Position	Email Address	Telephone No.
Person 1
Person 2

Budget

Complete the following budget breakdown, specifying the costs associated with your project. Please keep in mind the following points:

• Expenses to be covered by the Loblaw Water Fund must be clearly identified.

• Expenses must relate directly to the activities in your workplan. Show how estimates were made for any line items over $1,000 (e.g., GIS technician = $200/day, 10 days x $200.00 = $2,000.00)

• The Loblaw Water Fund will not fund 100% of the project costs; at least 25% matching funds from other sources must be secured (matching funds can include in-kind donations).

• In-kind donations can be included under Revenue and include donated services, equipment, materials, and volunteer time.

• Show all sources of funding and contributions.

Revenue

	Name of Agency	Amount ($)	Secured? (yes/no)	If no, list expected confirmation date (yyyy/mm/dd)
Loblaw Water Fund Grant Requested (Max $25,000)
Government grants
Foundation grants
Private sector funding
Funding from individuals
In-kind donations (can include donated services, equipment, materials, and volunteer time)
Other (please specify)

Total

	Amount ($)
Total Project Revenue

Budget justification. Explain how the value of in-kind contributions has been determined, and provide any other additional revenue information as needed.

EXPENSES

Specify expense details and amounts ($) from:

	Expense details	Loblaw Water Fund ($)	Other ($)
Total staffing costs (Specify positions, full time, part time)
Total supplies and equipment costs (Specify equipment and field supplies)
Total travel costs (Detail trips and costs)
Total of other costs (Please specify)

Total

	Loblaw Water Fund	Other
Total Project Expenses

Budget justification: Provide the names and brief qualifications of people that will be paid salaries or fees, and any other additional expense information as needed.

Permits and Volunteer Support

Would you welcome visitors in your field work?

Yes

No

I confirm that the appropriate permits and/or licences have been obtained, or will be obtained in time for the proposed work to be completed.

Yes

No

I have read and understand the Loblaw Water Fund Guidelines, and verify that the information provided in this application is accurate and true to the best of my knowledge.

Yes, I understand!

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