Funded by
Application Form
This PDF is intended for informational purposes only to help you plan your
application. This document cannot be submitted as your application. All
applications must be submitted via the Healthy Communities Initiative online
platform. If you require a PDF for accessibility reasons please reach out to
Application Instructions & Eligibility Confirmation
Our goal is to make this application simple and easy to complete. The Applicant Guide provides
more guidance and specific examples.
Projects funded by the Healthy Communities Initiative will:
respond to identified needs arising from impacts of COVID-19;
create and adapt public spaces, and programming and services for public spaces in the public interest;
demonstrate consideration of and connections with the community;
serve the general public or a community disproportionately impacted by COVID-19 listed in the
Applicant Guide; and,
fall within the three Healthy Communities Initiative theme areas described in the Applicant Guide.
The information you provide in this document will be used by local reviewers in their evaluation as they
make funding decisions according to the criteria above.
What type of eligible organization are you:
Section 1: About Your Organization
1. Lead Applicant Information
Phone Number:
Preferred Language:
If you selected municipalities
and municipal bodies are you:
Municipalities and local or
regional governments
established by or under
provincial or territorial statute
Municipally-owned corporation
If you selected Indigenous
governing body are you:
A band council
A First Nation, Inuit or Métis
government or authority
Tribal councils, provincial/
territorial bodies
If you selected federally or provincially incorporated
not for profit are you:
local economic development
group (inc BIAs)
registered charity;
federally or provincially
incorporated community, non-
profit, voluntary organization;
research institutes;
not-for-profit residents
educational institutions
Indigenous development
relevant not-for-profit
professional associations
Note: If you select "Other community-led organizations and grassroots
groups" you must apply with another organization that is listed as
eligible using an Intermediary Agreement.
Not eligible
English | Anglais
Province / Territory
Postal Code
3. Tell us about your organizations background, mission, and mandate. (Maximum: 200 words)
2. Organization Information
Street Address
City / Town / First Nation
Year Established:
Please describe the mission, mandate and main activities of your organization. Who do you serve? How do they benefit?
4. Community engagement
Please describe relationships with your community (including equity seeking groups and those with specific
socioeconomic needs) and how community engagement is integrated into your work (See Equity Guidance)
5. Are you applying as an individual organization or as a group of organizations?
If group, please describe the group.
How did the collaboration form? Who is participating in the collaborative? Are grassroots/community collaborators part of the
project? If so, what are their roles within it and have you fairly budgeted to reflect their contributions to the project? How will each
collaborator be publicly recognized for their contributions?
6. How did you hear about CHCI?
Contribution by Jay Pitter, MES
Organization Website:
Organization Name:
Organization Address:
If you are applying as a community-led organization or group with another eligible organization using an Intermediary Agreement
please attach contact information for both organizations.
Social media platforms:
Individual Organization
Section 2: About Your Project
Applicant Guide | Equity Guidance
7. Project Title:
8. Which Healthy Communities Initiative theme does your project primarily focus on?
Please describe your project. How does your project address the CHCI theme(s) and benefit the public during COVID-19?
What are the project’s desired outcomes? Please let us know if your project has any continued community benefits.
What was the inspiration or need that led to this project idea? Please describe how your community has shaped your project
proposal. Have you considered any unintended, adverse outcomes for your community, including equity-seeking groups?
Are individuals representative of the community(ies) you're seeking to serve involved in the decision
making and delivery of your project?
10. Tell us why this project is important and how you’ve engaged your community in it’s design.
(Minimum: 50 words; Maximum: 250 words)
11. Tell us about your project leadership.
9. Tell us about your project. (Minimum: 50 words; Maximum: 250 words)
Please refer to the Applicant Guide for a list of examples under each theme
Does your project focus on any other Healthy Communities Initiative themes?
Safe and vibrant public spaces
Improved mobility options Digital solutions
If yes, please give further details:
Yes No
Safe and vibrant public spaces
Please describe your project design, details of your work plan, and any important timelines. How will you gather stories and
lessons throughout the duration of your project?
12. Tell us about your project design, work plan & timeline. (Minimum: 50 words; Maximum: 250 words)
13. Attach up to five photos of your project site(s) to your application, if possible. Add disclaimer if
faces are in photo.
14. Tell us about your outreach strategy once the project begins.(Minimum: 50 words;
Maximum: 250 words)
your project reach the communities that you wish to serve? Please speak to specific outreach strategies.
15. If you've selected digital solutions as your Healthy Communities theme, tell us how you will use
inclusive digital design and manage data responsibly. (Minimum: 50 words; Maximum: 250 words)
Please describe how your project addresses user accessibility, data security & privacy of personal information, data
management, technology procurement & vendor selection, open data plan.
16. Possible Mentor Opportunity
If your application is successful , this information will be used to inform potential mentoring opportunities.
If the project being proposed is new to your organization in terms of activity and/or scope or integrating an equity lens is new,
do you think your project could benefit from a mentor?
If yes, in what area?
17. Communities Served. Is your project serving the general public or a community disproportionately
affected by COVID-19, including historically marginalized communities?
General public
Communities disproportionately affected by COVID-19
Support with community engagement
18. Permits & approvals. Have you secured the proper permits or approvals to successfully carry out this
project? We strongly encourage you to visit your local government authorities for relevant permits and approvals
Based on your answer above, please describe what permits or approvals are required to deliver the
projects. Applicants who receive funding will be required to submit proof of these documents prior to
funds being distributed.
If you selected communities disproportionately affected by COVID-19, select the primary community
requiring specific support, community of origin and age group your project will serve, if applicable:
20. Funding Request Range
19. Project Documents. You can attach additional documentation to support your application. Supporting
document examples: Project proposal, design drawings,
consultation documentation, letters of support,
certificate of insurance, site photos, etc
Section 3: Location, Budget and Timing
$5,000 to $100,000
21. Project Region(s)
Check the region map to determine in which region(s) your project takes place using the search tool
available on our website.
Over $100,000 up to $250,000
21. Funding Request
How much are you applying for?
Does your project take place in one region or more than one region?
one region more than one region
Will your project continue if you
are awarded a smaller amount?
Other communities served:
Members of LGBTQ2S+ community
Women, girls & non-binary people
Official Language Minority Communities
Newcomers, temporary foreign workers
and refugees
People experiencing domestic or
gender-based violence
People experiencing homelessness
People experiencing low income or
living in poverty
People living in group homes or
supportive care
People living with mental illness
People living with addiction
People with different abilities
Indigenous: First Nations
Indigenous: Inuit
Indigenous: Metis
Indigenous: All
People of African descent
People of Asian descent
People of Latin
American descent
People of Middle
Eastern descent
Other communities
of origin
Children and youth
Community requiring specific support:
Community of origin:
Age group:
Unsure (we are unsure of what we might need)
23. Project Budget Attach your project budget using the budget template
Ensure that your budget accounts for the full amount you have requested.
Please visit budget equity checklist: Download budget template
All budget items must be project-related and must be incurred between April 1, 2020 - June 30, 2022.
Eligible expenditures include: wages and benefits, professional fees, travel and accommodations, materials and
supplies, printing and communication, equipment rental/lease/maintenance, administration costs, and disability
support for staff. See the Applicant Guide for more details about eligible expenses.
22. Is your project located at a single site or multiple sites?
Single site
Multiple sites
Please select the region(s) where your project takes place:
Alberta North
Alberta South
Atlantic Canada
BC North & Island
BC South
ON - South Western
ON - Golden
ON - Toronto, York
& Durham
ON - Central Eastern
Note: Project activities must be completed and
project expenses must be spent by June 30, 2022
23. Start and End Dates. What are the start and end dates of your project activities?
Start date:
Budget Notes. Please add any budget notes or commentary, if needed.
Conflict of Interest Act, the Parliament of Canada Act and the Lobbying Act.
Conflict of Interest disclosure. Please describe who these individuals are, their roles and responsibilities as public
servants as well as the ways in which they will be working on the CHCI-funded project.
End date:
Northern Canada &
ON - Northern
QC - Boreal
QC - Central and
QC - Montreal, Laval
and Montérégie
QC - Lanaudière,
Laurentides, Outaouais
Section 4: Declarations and Authorizations
Money owed to Government of Canada Does the organization owe any amount to the Government
of Canada?
Money owed to Government of Canada disclosure.
What is the name of the program through which you have secured Government of Canada funding (loans
or otherwise), what amount of funding was secured and what is the repayment plan?
Conflict of Interest Declaration. Will there be involvement of former public servants who are subject to
the Post-employment Measures of the Values and Ethics Code for the Public Service, the Conflict of
Interest and Post-Employment Code for Public Office Holders, the Conflict of Interest Act, the Parliament
of Canada Act and the Lobbying Act.
Organizational Status Documentation. Please provide at least one piece of documentation confirming
your organizational status as an eligible organization. This can include, but is not limited to Articles of
Incorporation, Business Number Registration Charitable Status, etc.
We declare our interest in submitting this application for consideration of the Canada Healthy
Communities Initiative
We confirm that the information provided in this application is accurate, and that it may be shared
and used in the work of Community Foundations of Canada, community foundation network,
Canadian Urban Institute, technical partners and the Government of Canada
I have appropriate signing authority to submit this proposal on behalf of the organization/
I agree that our application will be shared with your selected regional hub for review.
I understand that, if our application is approved, electronic payment will speed up the
disbursement process by approximately two weeks. (If your organization is not set up to receive
Electronic Fund Transfers (EFT), you may wish to set that up now. If you prefer, you can receive a
cheque via mail.)
I accept the authorizations and confirmations
No Yes
Please describe who these individuals are, their roles and responsibilities as public servants as well as the
ways in which they will be working on the project.
Conflict of Interest disclosure
By completing this section, the applicant confirms that they are an eligible organization or eligible applicant.
click to sign
click to edit