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Approved________________

2012 Not Approved________________NEW PROJECT PROPOSAL

Grant Requests must be turned prior to the November 8th Drug Free Meeting

Directions: Please complete the following information. Use additional sheets if necessary.

Implementing Agency: _____________________________ Name ofProposal:____________________________________

Contact Person: _______________________________Title:____________________________Phone_____________________

Type of Program (Please check one): Prevention/Education ( ) Treatment ( ) Justice ( )

Starting Date: _______________ Ending Date: ___________________

Target Population:___________________ Estimate # of Persons Served orImpacted:_____________________________

Brief description of

program:________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Goals and Objectives for Program:

Goal

1:____________________________________________________________________________________________________

Objective1:1_______________________________________________________________________________________

Objective

2:1_______________________________________________________________________________________

Goal

2:____________________________________________________________________________________________________

Objective

1:2_______________________________________________________________________________________

Objective

2:2_______________________________________________________________________________________

Goal

3:____________________________________________________________________________________________________

Objective

1:3_______________________________________________________________________________________

Objective

2:3_______________________________________________________________________________________

Steps for Implementation of Program:1._________________________________________________________________________________________________________

CFDFOC

Citizens for a Drug Free OhioCounty

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2._________________________________________________________________________________________________________

3._________________________________________________________________________________________________________

4._________________________________________________________________________________________________________

Amount Requested:____________________

Implementing Agency Signature:I, the undersigned, affirm that I am of, and support, this proposal for funding of this program from

the State Drug-Free Communities Fund.

Signature Title Date

________________________________________________________________________________________

To: All ApplicantsFrom: Citizens for a Drug Free Ohio County

The Citizens for a Drug Free Ohio County is interested in the needs of you

organization. The County Commissioners are responsible for the allocation decisions othe Drug-Free Communities Funds, with the County Council making the actuaappropriations to the Citizens for Ohio County Drug Free Community Committee.

These funds can only be used to carry out recommended actions contained in acomprehensive drug-free communities plan approved by the Commission for a DrugFree Indiana. At least 25% of these funds must go to each of the following three serviceareas:

Prevention and educationIntervention and treatmentCriminal Justice

Funds from the Prevention and Education service area will be limited to $1000.00 pergrant request.

The following are the guidelines for distribution of local funds.A. Goals for proposed program must be established.B. Objectives must be measurable and have a completion date attached to them

be specific.C. Goals and objectives must satisfy requirements of the Governors Commission

for a Drug Free Community.D. Methods for implementation must be listed.

E. Those requesting funds for the organization must attend 6 meetings per year.F. A written evaluation and oral presentation is required within 2 months of thecompletion date of program.

G. Additional funding will not be provided unless previous grants obligationshave been fulfilled.

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Citizens for a Drug-Free Ohio County

Evaluation Report

Implementing Agency: __________________________ Project Title:____________________________

Contact Person: __________________________Title: ___________________Phone:________________

Date of Written Report: ___________________ Date of Oral presentation:_____________________

Type of Program: Prevention/Education ( ) Treatment ( ) Justice ( )

Amount Requested:____________________ Amount Spent:___________________

Starting Date:__________________ Ending Date:____________________

Program Description:

Goals and Objectives of Program:

To what degree did you accomplish your established goals and objectives?

CFDFOC

Citizens for a Drug Free Ohioounty

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Did you experience any barriers that kept you from meeting your goals?

Population Served (indicate numbers)

Check all special target populations reached:

__________Parents __________Elderly __________High-risk youth __________Minorities __________Economically Disadvantaged __________Other-specify:__________

Children: to grade 6____________ Young Adults__________________

Children: Middle/Jr. High_______ Adults 26 to 54_______________

Children: High School___________ Senior Adults 55 up___________

PLEASE ATTACH CLIPPINGS, FLYERS, BROCHURES, ETC. RELEVANT TO THEPROJECT.

Report submitted by: ____________________________________ date________________________

Telephone number of person submitting report:

________________________________________