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Click Here: What you need to know before joining (Next Era Scope of Work)

Organization Name (required)

Name of Person Writing Grant (required)

If funded, person responsible for management and implementation of grant

Organizational Tax ID Number

Mailing Address (for Checks):

Physical Address (for anything that needs to be shipped, if your mailing address is a PO
BOX)

Phone number, Fax Number and Email Address

AUTHORIZATION INFORMATION

Person Authorized to Sign Contract

ORGANIZATION

Type of Organization (SELECT ALL THAT APPLY)
Community-Based OrganizationHealth Care ProviderFaith-Based OrganizationYouth-Focused OrganizationGovernment OrganizationAdvocacy OrganizationEducational InstitutionTax-Exempt 501(c)(3) organizationAmerican Indian TribeOther

PROJECT SERVICE AREA

What Public Health Region will this grant serve?
Region 1 Jefferson, Orleans, Plaquemines and St. BernardRegion 2 Ascension, East Baton Rouge, East Feliciana, Iberville, Point Coupee, West BatonRouge, and West FelicianaRegion 3 Assumption, Lafourche, St. Charles, St. James, St. John the Baptist, St. Mary, and TerrebonneRegion 4 Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin, and VermillionRegion 5 Allen, Beauregard, Calcasieu, Cameron, and Jefferson DavisRegion 6 Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon, and WinnRegion 7 Beinville, Bossier, Caddo, Claiborne, DeSoto, Natchitoches, Red River, Sabine, andWebsterRegion 8 Caldwell, East Carroll, Franklin, Jackson, Lincoln, Madison, Morehouse, Ouachita,Richland, Tensas, Union, and West CarrollRegion 9 Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington

What Parish(es) will this grant serve?

Does your organization have capacity to host meetings or trainings?

If so, what is the capacity limit?

Applicant Capacity

TFL is searching for grantees that have demonstrated ability and experience in community organizing, community planning, health education and promotion, coalition building, advocacy, policy, training, and/or tobacco prevention and control.

Priority will be given to applicants who engage youth aged 13-18 in current programming, promote youth advocacy participation and engagement, and have the ability to provide transportation to and from required activities.

Describe your organization’s:
• Mission and purpose.
• Specify the type of organization (school, church, or other).
• Staffing and administrative capacity.
• Experience in health education and promotion, advocacy, policy, training, and/or tobacco prevention
and control.
• Experience with youth ages 13-17 and with youth advocacy, participation and engagement, and outcomes in your community.
• Experience with community event planning. Please provide examples; include purpose/call to action,
outcomes, challenges, etc.

Applicant Response: (Upload your information below in word or PDF document. Please
limit your response to 5 pages double-spaced text.)
Allowed file types: Word,Excel,PPT,PDF

Application Appendix Content Sheet

Please provide: IRS Letter showing your organizations 501c3 ta exempt status
High Schools must provide their IRS 990 report
Your organization's proof of liability insurance
Allowed file types: Word,Excel,PPT,PDF

Does your organization have a Diversity, Equity and Inclusion or something similar statement? *
YesNo

If your organization does have a Diversity, Equity and Inclusion (DEI) statement, please
upload it here.

Allowed file types: Word,Excel,PPT,PDF

Does your organization have a Safe Place or similar policy? *
YesNo

If your organization does have a Safe Space or similar policy, please upload it here.

Allowed file types: Word,Excel,PPT,PDF

Diversity and Inclusion Statement

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