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2. SHIP Community Partner Award Application 2023

   Prior to completing this application, please review the Anoka County SHIP Community Partner Award Instructions. Any questions about the application can be sent to SHIP@co.anoka.mn.us or call 763-324-4200

4. Anoka County SHIP Community Partner Award Instructions
   View instructions here
8. Organization / Group Information
10. Today's Date*
11. Organization/Group Name*
13. Organization/Group Address*
15. Name of Primary Contact*
16. Phone Number of Primary Contact*
18. Email Address of Primary Contact*
19. What is preferred method of contact?

    1. Phone
    2. Email
23. Which option best describes your primary organizational structure?

    1. For-profit
    2. Non-profit 501(c)3

    1. Non-profit - Other*
    2. Public Agency/Government
25. *Other:
27. Which options best describe your organization's industry or primary focus?

    (Mark all that apply)

    1. Retial
    2. Manufacturing
    3. Human Services
    4. Sales/Consulting
    5. Business Services
    6. Insurance
    7. Real Estat/Housing
    8. Information Technology
    9. Environmental Services

    1. Faith Community
    2. Advocacy/Outreach
    3. Arts
    4. Media/Communications
    5. Agriculture
    6. Education
    7. Healthcare
    8. Trades/Construction
    9. Other**
29. **Other
31. Give a brief explanation/background of your organization/group.*
35. Project Information
37. Please select at least one primary category and additional secondary categories as approprieate

    See instructions for what each selection includes in detail.

    1. MN EATS (Healthy eating, lactation support, etc.)
    2. MN MOVES (Movement, physical activity, biking, etc.)
    3. MN Well-Being (Social connection, addressing trauma, etc.)
    4. MN Commercial Tobacco Free (CTF) (Tobacco/vaping prevention)
39. Description*
    Provide a general description of the project and please include an explanation for why the project is needed. Please list any other organizations or partnerships that may be involved in this project (if applicable).
41. Project Goal(s)*
    What are the goals of the project? Project goals must contribute to one of the three Top Areas listed in the Instructions sheet.
43. Please describe what Policy, System, or Environmental Change(s) this project will address.

    See instructions for descriptions of each.

45. Policy:
46. System:
47. Environmental:
49. Health Equity*

    Please describe how this project is increasing opportunities that would not otherwise be available or accessible to this population.

51. Number of people who will benefit from this project:
55. Action Plan and Timeline
    List the activities needed to accomplish the project and the timeline for completing them. Add more lines as needed.
57. Action Plan/Activities
58. Timeline
60. Action Plan/Activities
61. Timeline
63. Action Plan/Activities
64. Timeline
66. Action Plan/Activities
67. Timeline
69. Action Plan / Activities
70. Timeline
72. Action Plan / Activities
73. Timeline
75. Action Plan / Activities
76. Timeline
78. Action Plan / Activities
79. Timeline
81. Feel free to attach a document with more lines as needed.
85. Budget
    Include all projected budget items, such as equipment, materials, training fees, printing, etc. Add more lines as needed. Please include links to specific items as needed. All approved and agreed upon items will be purchased directly by Anoka County SHIP.*
87. Attach Completed Budget and Order Form

    Anoka County SHIP Community Partner Awards Budget and Order Form

88. Total Amount Requested:*
90. * SHIP funding cannot be used for labor/installation costs, alcohol/illegal substances, capital improvements, clothing, lobbying, fitness center memberships, raffles, etc. Approval of items is determined by the MDH SHIP Financial Guidance and Anoka County SHIP discretion.
92. Evaluation Plan*
    What would indicate to you that this project was successful?
94. Ship requires all projects to include evaluation. Are you willing to work with SHIP staff to come up with an evaluation plan?*

    1. Yes
    2. No
96. Sustainability*
    What is the plan for making sure the project continues after funding ends?
98. Communications*

    Who needs to know about this project - community members, community leaders, etc? How will you communicate with these groups?

102. By signing the Project Application, you agree:

     (no need to check these boxes)

     1. Obtain leadership and, if convened, wellness committee support for proposed SHIP project.
     2. To ensure the project implementation and any final products as a result of the project are located in Anoka County, MN.
     3. Submit a completed budget form and return correspondence with SHIP in a timely manner regarding changes, alterations, or clarifications within 5-10 business days.
     4. To complete a Memorandum of Understanding, if required, per Anoka County or MN Dept. of Health.
     5. To complete a media release providing consent to Anoka County SHIP and its partners to share media regarding your project or organization with the public.
     6. To provide before-and-after photos of the project site for evaluation purposes.
     7. Communicate with Anoka County SHIP on a regular basis throughout the grant cycle to provide updates, including a final summary.
104. Signature*
     Type your name to confirm you've read and agree to the requirements.
105. Date*
     Date

107. For questions about the application, including assistance in completing the application (additional formats, translations, etc.) please email SHIP@co.anoka.mn.us or call 763-324-4200. 

Leave This Blank:


109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit

* indicates a required field