Group Information
Name
Address
Phone	Fax
Email	Website Address
Charitable/Non Profit Organization registration # (if applicable)	Our Group has a bank account in the name of our organization Yes No
Briefly describe what your group does:
Projects Contacts
Name	Name
Title	Title
Phone (work)	Phone (work)
Phone (home)	Phone (home)
Email	Email
Project Summary

For Office Use Only - Project No.:

Appendix 2 Senior Grant Application Form

Title
Location of Project
		)
Start Date of Project	End Date

BUDGET FORM – HUMAN RESOURCES

BUDGET FORM

Please also provide a cost summary including (please use attached budget forms on pages 4 and 5 to this application to provide details of the costs)
Total Project Cost	Amount requested from the Senior Grant
Amount from other sources	In- Kind support hours

APPLICANT’S SIGNATURE

BUDGET FORM – HUMAN RESOURCES (Volunteers)

Service	Details		In- Kind Value (in hours worked)
	Number of People	Estimated Time for Each hour)
(e.g. Volunteer planters)	10	10	100
d
Total

BUDGET FORM

Project Costs	Cost			Senior Grant	Other
	# of units	Unit Cost $	Total Cost $
	500	1.00	500.00	200.00	300.00
Total

How did you organization hear about the Senior Grant? (Please check one)
Town Website	Newspaper advertisement	Word of mouth	Other
Upon completion of this Project please submit your project report, as well as original invoices, photos and records to.

Applicant’s Signature

I hereby make application for funding from the Senior Grant Fund, declaring that all information contained herein is true and correct and acknowledging that the Town of Markham will assess this application based upon the information contained in this application.

If approved for funding I further acknowledge and agree:

1. to comply with all relevant policies and secure all permits required for this project and acknowledge that the Town bears no responsibility or has any liability in any manner with respect to this project.

2. that the Town reserves the right to review communications and communication materials to be presented to the public to ensure compliance with Town policies, including the Town’s Communication Standards.

3. to allow the Town of Markham to use the project name and any images associated with the project to promote the Senior Grant Fund.

5. to return all unspent funds to the Town of Markham upon completion of the project.

6. that there shall be no personal benefit directly, or indirectly, from this funding and I will notify the Town of any conflict of interest situation should it arise in carrying out of the project.

.

Signature Title

Printed Name Date

Submission of this application form does not guarantee approval of your application.

FOR OFFICE USE ONLY
Date Application Received		New Applicant?	Yes No
Approved/Not Approved	Yes No
Acknowledgement Letter Sent?	Yes No	Date Sent
Letter of Approval or Rejection Sent?	Yes No	Date Sent
Final Report Received?	Yes No	Date Received
Photos Received?	Yes No	Date Received
Consent for Photographs received	Yes No	Photos posted on website?	Yes No

Personal information contained herein is subject to the Municipal Freedom of Information Act and the Personal Protection and Electronic Documents Act. The information collected may be used for promotional purposes. Completion of this form constitutes consent by the applicant to these terms and uses.

Senior Grant Fund

Photo Consent and Release Form

I, ____________________________________________________________ hereby permit and authorize the (Print in full – first, middle initial & last name) Town of Markham (the “Town”) to take my photograph/image.

I acknowledge and agree that the Town may publish or use the image for any Town purposes by any means whatsoever including, but not limited to electronic or digital means. I acknowledge that the Town may not be able to control the distribution or use of the image by other than Town representatives.

I agree that this Consent and Release is given in perpetuity and for no consideration, credit, acknowledgment or financial recompense, now and in the future.

I hereby hold the Town harmless for any claims, actions, debts, damages, injuries or losses that may arise or be incurred as a result of the taking, use, publication or distribution of the image and I agree to indemnify the Town against any third party claims, actions, damages, injuries or losses brought or assessed against or incurred by the Town for the use of the image(s).

Contact Information
Signature	Date
Address
Town	Province		Postal Code
Telephone		Email
Town of Markham:
Town Representative	Date