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SRD Board Members Scott Aune Sarah Mikesell Growney Matt Hall Dan Haman Tony Hult Jacob Ivanoff Sandy Newsome Dossie Overfield Alan Rosenbaum Dave Treick Stan Wolz Shoshone Recreation District 1402 Heart Mountain Street PO Box 1531 Cody WY 82414 (307) 527-3484 [EMAIL REDACTED] Rick Manchester Director (307) 527-3485 [EMAIL REDACTED] Jo Selk Administrative Secretary Shoshone Recreation District (SRD) Requesting Proposals for Funding Groups & Organizations Grant Application Form • FY 2013/2014 Application Deadline • Friday, April 12, 2013 Recreation oriented, non-profit organizations within the boundaries of Park County School District #6 are invited to apply for funding. Grant applications are due no later than Friday, April 12, 2013 – 4:00 PM. Grants are spent July 1 – June 30. The Shoshone Recreation District has a common goal of providing healthful and creative recreation programs, facilities and activities to meet the needs of the residents of the District. To be considered for a grant, non-profit recreation oriented organizations should provide the following detailed information relating to your request and organization: 1. A completed application form with relevant attachments before Friday, April 12, 2013 – 4:00 PM. Grant application form is available @ http://www.cityofcody- wy.gov/index.aspx?NID=175 Send to: Shoshone Recreation District PO Box 1531 – Cody WY 82414 Deliver or email to: 1402 Heart Mountain Street (Rec Center) Attention: Shoshone Recreation District Rick Manchester or Jo Selk [EMAIL REDACTED] [EMAIL REDACTED] Questions: 527-3484 Rick Manchester 527-3485 Jo Selk 2. Required Attachments: • Current year organizational budget summary. • Most recent balance sheet and income statement. 3. Applicants will be notified by mail, telephone or e-mail after the board has reviewed all applications. At the discretion of the SRD Board, group presentations and interviews are not required. If a presentation is required, the organization will be contacted and presentations will be scheduled on the evening on Wednesday, April 24, 2013. Page 1 of 5 ---PAGE BREAK--- Shoshone Recreation District Grant Application Form FY 2013/2014 (Please type or print legibly) Organization Requesting Funding Is your organization incorporated as a non-profit organization under WY State Law? Yes No Type of recreation oriented organization: NOT-FOR-PROFIT W/ IRS 501 3 STATUS ― Number: OTHER (PLEASE INDICATE) HOW LONG HAS YOUR ORGANIZATION BEEN IN EXISTENCE Is this your first request for funding? Mailing Address Authorized Representative’s Name & Title Phone(s) E-Mail Secondary Representative’s Name & Title Phone(s) E-Mail 1. List of Current Board Members 2. What recreation services are provided by your organization? 3. What plans have been made by your organization to financially sustain the organization without this grant? How is the organization prepared for an unexpected loss of revenue? Page 2 of 5 ---PAGE BREAK--- 4. Funding Requested for Fiscal Year 2013/2014 Projects & events must take place during the fiscal year ― July 1, 2013 – June 30, 2014. Purpose of Funding How will the grant be used? Total Requested Amount $ Is it feasible to purchase equipment/materials in Park County School District Comments: Yes No Will any of the funding requested be used for grant matching? If yes, attach a list of grants & project descriptions, grant amounts and associated matching requirements. Yes No If your organization received SRD grant funds in the past how were the funds used and was it successful? Yes No Comments: Page 3 of 5 ---PAGE BREAK--- 5. Does your organization make available scholarships to participate in your program? 6. Is your program available to participants with all skills and abilities? Is there a selection/reduction process that limits the number of individuals involved? 7. Number of Park County School District #6 Residents and Non-Residents Served Number of Park County School District #6 Residents and Non-Residents Served Number of Program Days Age Groups Participant Fees 2013 (Projected) Residents Non-Residents 2012 (Actual) Residents Non-Residents 8. What if your organization does not receive this grant? Page 4 of 5 ---PAGE BREAK--- Funding Sources ― Attach separate list if additional space is needed. Source (Name & location of funding sources) Amount of Funding Requested / Approved Funding Use Example: Park County Parks & Rec Board $5,000 ― Approved Football Equipment Example: Sponsor Name $5,000 ― Requested Uniforms Available Financial Resources of Organization Requesting Funding: Total Annual Operating Budget Total Operating Reserves Savings account(s) $ $ I certify that all of the information provided on this application is true and complete to the best of my knowledge. Liability insurance coverage is also required for the Organization identified on this application. I understand that if asked by an authorized official of the Shoshone Recreation District, I agree to give proof of the information that I have given on this application and to provide certificate of liability insurance, coverage period and type of coverage. Your group/organization agrees to indemnify the Shoshone Recreation District of any liability associated with the use of such funds and certifies that this grant request has been approved by the governing board(s). Date: Authorized Representative’s Signature: Title: Page 5 of 5 SIGN