COMMUNITY CENTER APPLICATION
A P P L I C A T I O N P
R O C E S S:
·
Complete and sign the application form
·
Include required paperwork
·
Mail or fax to RTSD
Rebuilding
Together
Fax: (619)
231-7870
For more information or questions call (619) 231-7873
PROGRAM INFORMATION:
Rebuilding Together San
Diego is a volunteer program designed to provide free renovation services to
elderly, disabled and low-income homeowners and nonprofit community centers in
We help homeowners who cannot physically or financially address their home repair needs themselves, and community centers that do not have the financial resources to complete the needed facility repairs.
Homeowners and community center representatives are expected to actively participate, as part of the team during the entire program.
·
There is
no charge for our services. In some cases, community facility who have the
available funding, are asked to partner and share in the cost of materials and
supplies for the benefit of their center, along with volunteer support.
·
The
Project Selection Committee determines which community centers will be selected
based upon: our mission, the number of applications, the need of the agency
& if they are serving the needs of the community, our ability to complete
the required repairs, and the participation and involvement of the applicant.
·
We are
limited in the type of work we can do.
Due to size and complexity of the work needed, we may not be able to do
certain projects. Work completed at each site is different.
·
Rebuilding
Together
ELIGIBILITY REQUIREMENTS:
·
The facility must be located in
· The organization must be a registered 501(c)(3) or public school.
· The organization must serve the needs of our constituents – low income, seniors and/or persons with disabilities.
· The organization must show a demonstrated need for our services.
· The organization must own the property or have a long-term lease on the property.
REQUIRED DOCUMENTS TO BE SUBMITTED WITH
APPLICATION:
ü A completed application
ü A copy of the organization’s current operating budget
ü A copy of the organization’s operating budget and financial statement
ü A copy of the deed to the property or a copy of a long-term lease.
ü Proof of 501 (c) (3) status (not required for public schools)
ü A list of Board of Directors/School Board and their professional affiliation
ü Fact Sheet that describes the organization and its mission
REBUILDING TOGETHER
______________________________________________________ _____________________________
Name of Organization / Site Name (if different) Executive Director
______________________________________________________ _____________________________
Mailing Address City,
Zip Code
______________________________________________________ _____________________________
Project Address (if different) including City & Zip Site Contact name/Title
________________________ _______________________ _____________________________
Main Phone Number Site
Contact Phone Number Emergency
Phone Number
E-mail Address Site
Contact E-mail Address
Person filling out application
Describe the mission of your organization and whom it
serves:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
How does your organization specifically serve your clients?
_________________________________________________________________________________________
_________________________________________________________________________________________
What are your organization’s major sources of funding?
_________________________________________________________________________________________
Please provide any further information about your organization that may
help us in evaluating your application (i.e. extent of repairs, budget
concerns, impact on clients/programs, etc.)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
STATISTICAL INFORMATION:
* If you are a multi-site non-profit, please provide the breakdown of total population served and the applicant site. Note: Rough estimates are acceptable
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Total |
Applicant Site* |
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Total Number of Clients served |
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Number of Elderly |
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Number of Children |
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Number of persons with disabilities |
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Number of low-income** |
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**Please describe your basis for low-income: 80%/50%/30% of county median income
|
Race Categories OF CLIENTS (Required
for grant reporting) |
Ethnicity |
||
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Check if also Hispanic |
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Total / Site* |
Total / Site* |
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1 |
American Indian or |
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2 |
Asian |
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3 |
Black or African American |
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4 |
Native Hawaiian or Other Pacific Islander |
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5 |
White |
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6 |
American Indian or |
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7 |
Asian and White |
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8 |
Black or African American and White |
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9 |
American Indian or |
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|
10 |
Other |
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*If you are a multi-site non-profit, please provide the breakdown
of total population served and the applicant site. Note: Rough estimates are acceptable
FACILITY INFORMATION:
Year the facility was built: Approximate number of rooms:
Please list your top repair priorities
1.______________________________________ 2._____________________________________
3.______________________________________ 4._____________________________________
Additional repairs you would like to see done:
__________________________________________________________________________________________________________________________________________________________________________________
Please explain why your organization has not been able to complete the
above repairs:
__________________________________________________________________________________________________________________________________________________________________________________
If your facility is selected, able-bodied staff, clients, board of directors and friends are expected to participate. Please describe how your organization will assist our volunteers:
_________________________________________________________________________________________
_________________________________________________________________________________________
Can this site accommodate at least 50+ volunteers for a one-day
project?
YES______ NO________ If NO, how many volunteers?__________
How did you hear about our program?________________________________________________________
Has your organization been a recipient in the past? If so, when?
(Please note that priority will be given to first-time recipients)
Are there any other non-profits that you are aware of that could
benefit from our program?_________________________________________________________________________________
_________________________________________________________________________________________
AUTHORIZATION STATEMENT:
I/we
certify that the above information is true and correct to the best of my/our
knowledge. I/we realize that failure to
provide all information requested could result in our application being
invalid. I/we authorize you to check any
references necessary to complete the processing of this application for the purpose of receiving facility rehabilitation through
Rebuilding Together San Diego. I/we also
understand that any information received will be kept
confidential and will be used strictly for determining my/our eligibility for
this program.
___________________________________________________________ ____________________
Applicant Signature Date
Please remember that this application must be submitted
with the requested documents mentioned in the
beginning
of this application to be considered.