EmailMe Form - 2023 CHIP Grant Report - Program/Project Funding

2023 CHIP Grant Report - Program/Project Funding

Please submit this form by April 26th, 2024 at 11:59 pm.

In addition to this form, you must submit:
- Program/Project Report Declaration
- Program/Project Reconciled Budget
- Supporting Materials

Failure to complete this report as agreed upon in the CHIP contract would result in a recall of allocated funds and a one-year suspension from the CHIP program. As such, additional applications for funding would not be accepted.

In addition to the completion of this form, please attach a reconciled budget and declaration form. These can be found at www.londonheritage.ca/chip/.

APPLICANT INFORMATION
Name of applicant (registered name if incorporated): *
Address *
City
Province
Postal / Zip Code
PRIMARY CONTACT
Name: *
First Last
Title: *
Phone: *
### - ### - ####
Email: *
MOST SENIOR OFFICIAL/SIGNING OFFICER
Name:
First Last
Title:
Phone:
### - ### - ####
Email:
Signing authority: *
Yes
No
Select the stream that you received funding for: *
Program Funding
Project Funding
Did you have additional sources of revenue?: *
Was additional revenue or funding generated due to support from CHIP?: *
If so, please explain how these resources have been used.
Funding received from CHIP: *
Total Budget: *
Include revenue sources including funding received from CHIP.
OPTION 1. PROGRAM FUNDING
Title of program:
Start date:
MM / DD / YYYY
End date:
MM / DD / YYYY
Attendance:
Provide a description of the program, timeline and activities that took place.
Provide details on whether the program is on-going or a new development.
Additional comments:
OPTION 2. PROJECT FUNDING
Title of project:
Start date:
MM / DD / YYYY
End date:
MM / DD / YYYY
Attendance:
Provide a description of the project, timeline and activities that took place.
Provide details on whether the project is on-going or a new development.
Additional comments:
FUNDING MEASUREMENTS
Based on the program or project, complete the following:

Number of: *

Full-time staff:
Part-time staff:
Contract staff:
Full-time staff supported by employment grants:
Part-time staff supported by employment grants:
Contract staff supported by employment grants:
Volunteers:
Volunteer hours:
New volunteers:

Based on your proposed goal (1), objectives (3) and outcomes (3-5) in your application, do you believe you were able to achieve these targets? *

Goal:

Objective:

Objective:

Objective:

Outcome:

Outcome:

Outcome:

Outcome:

Outcome:

Consider re-evaluating your original answers and make adjustments around the true result of your targets.
With reference to the objectives you listed above, describe any factors (positive or negative) that influenced your ability to be successful in your reaching your objectives.: *
Describe any additional accomplishments, challenges or lessons learned associated with this funding opportunity.: *
State the impact funding had on the museum and heritage sector in the London community.: *
In your experience, did CHIP funding support organizational development and the sector’s workforce?: *
Explain the overall impact of this funding. Why was this funding important?: *
Were you able to develop new programs, projects or operations due to this funding support? What were you able to accomplish? How many people did this funding impact?
Additional comments:
SECTOR STATISTICS
For the 2022 CHIP funding period, please include the most accurate representation of statistics available for your organization (if applicable).

Goal:
Objective:
Objective:
Objective:
Outcome:
Outcome:
Outcome:
Outcome:
Outcome:

Total Federal funding:
Total Provincial funding:
Total Municipal funding:
Total Private Sector funding:
Total Full-time staff:
Total Part-time staff:
Total Contract staff:
Total Full-time staff supported by employment grants:
Total Part-time staff supported by employment grants:
Total Contract staff supported by employment grants:
Total Volunteers:
Total Volunteer hours:
Total New volunteers:
Total number of operating days this year:
Total number of operating hours this year:
Total number of collaborations or partnerships that you held this year:
Total number of school groups and students that you managed this year:
Total number of community and private events that you managed this year:

RECONCILED BUDGET
Please ensure you fill out the Reconciled Budget provided by LHC. No other budget sheets will be accepted. This can be found at www.londonheritage.ca/chip/.
Reconciled Budget *
Include the program or project’s total reconciled budget, including revenue, expenses and funding received from CHIP.
SUPPORTING MATERIALS
Please upload a minimum of one 1 and a maximum of five 5 supporting materials for our files, including brochures, posters, flyers, photos, newspaper clippings, etc. with a brief description of each item. For video file uploads, please upload each file on YouTube and provide the link in the "description field" followed by a brief description (one link per description field). No more than 10 minutes worth of video in total.
Supporting Material 1 *
Description 1 *
Up to 150 words
Supporting Material 2
Description 2
Up to 150 words
Supporting Material 3
Description 3
Up to 150 words
Supporting Material 4
Description 4
Up to 150 words
Supporting Material 5
Description 5
Up to 150 words
Overall, how satisfied were you with the CHIP application process? *
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Please let us know of any feedback that you have regarding the CHIP application process. *
DECLARATION
Please ensure you fill out, sign and date the Report Declaration provided by LHC prior to upload. No other forms will be accepted. This can be found at www.londonheritage.ca/chip/.

Please ensure you read the content of the Declaration and sign and date it before you upload.
Signing officer: *
First Last
Title: *
Declaration: *
If you have any questions, please contact:

Richa Joy
Interim Fund Development Officer
rjoy@london.ca
519-930-2140 Ext 8455

London Heritage Council
201 King Street
London, ON N6A1C9
info@londonheritage.ca
www.londonheritage.ca
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APPLICANT INFORMATION

PRIMARY CONTACT

MOST SENIOR OFFICIAL/SIGNING OFFICER

OPTION 1. PROGRAM FUNDING

OPTION 2. PROJECT FUNDING

FUNDING MEASUREMENTS

SECTOR STATISTICS

RECONCILED BUDGET

SUPPORTING MATERIALS

DECLARATION