Adaptive Sport Equipment Grant Application Form

APPLICATION DEADLINES

Club/Community Organization (if applicable)
The club/community organization must submit the completed application to the respective Provincial Sport Organization (PSO), Multi-Sport Organization (MSO) or District for endorsement no later than March 22 and/or September 22 annually.

PSO/MSO/District
The PSO/MSO/District must review, sign and submit the application to the Sask Lotteries Trust Fund (Trust Fund) no later than April 1 and/or October 1 annually.

It is recommended that Fall/Winter sports apply by the Spring deadline and the Spring/Summer sports apply by the Fall deadline. Applications must be submitted to and approved by the Trust Fund before the start of the program.

Are you completing the Adaptive Sport Equipment Grant Application Form on behalf of a:*

Club/Community Organization
PSO/MSO/District
PSO Reviewing and Endorsing an Application Form

PLEASE NOTE: If you are a PSO/MSO/District reviewing and endorsing an Adaptive Sport Equipment Grant Application Form, you will need to change the selection to “PSO/MSO/District Reviewing and Endorsing an Application Form” in order to submit the form to Sask Sport.

CONTACT INFORMATION

Club or Community Organization*

Contact Name*

First Last

Position*

Phone*

Club or Community Organization Email*

Website*

PSO/MSO/District*

Contact Name*

First Last

Position:*

Phone*

PSO/MSO/District Email*

PSO/MSO/District Fiscal Year*

FUNDING INFORMATION

What is the grant amount being requested?*

Have you applied for funding assistance from any other source?*

Yes
No

Please explain your answer.*

EQUIPMENT INFORMATION

What sport(s) will the equipment be used for?*

Will this equipment be used in an Equipment Loan Program?*

Yes
No

When do you expect to order the equipment?*

When do you expect to receive the equipment?*

Any additional information regarding the equipment you would like to purchase:

ADAPTIVE SPORT EQUIPMENT QUOTATION INFORMATION

(List each different type of equipment, in priority order)

Technical Name of Equipment:*

Supplier’s Name:*

Quoted cost per unit:*

No. of units requested:*

Total cost:*

Total Request:*

Is there another piece of equipment to list?

Yes
No

Technical Name of Equipment:*

Supplier’s Name:*

Quoted cost per unit:*

No. of units requested:*

Total cost:*

Total Request:*

Is there another piece of equipment to list?*

Yes
No

Technical Name of Equipment:*

Supplier’s Name:*

Quoted cost per unit:*

No. of units requested:*

Total cost:*

Total Request:*

Is there another piece of equipment to list?*

Yes
No

Technical Name of Equipment:*

Supplier’s Name:*

Quoted cost per unit:*

No. of units requested:*

Total cost:*

Total Request:*

Is there another piece of equipment to list?*

Yes
No

Technical Name of Equipment:*

Supplier’s Name:*

Quoted cost per unit:*

No. of units requested:*

Total cost:*

Total Request:*

Is there another piece of equipment to list?*

Yes
No

Technical Name of Equipment:*

Supplier’s Name:*

Quoted cost per unit:*

No. of units requested:*

Total cost:*

Total Request:*

Please upload two quotes from equipment providers for each different type of equipment.*

Drop files here or

Max. file size: 32 MB.

Have you attached two quotes for each piece of equipment?*

Yes
No

Please provide an explanation why two quotes from equipment providers for the equipment have not been uploaded.*

PROGRAM INFORMATION

Program Name*

Type of application*

Provincial Program
Community Program

Please provide a brief description of the sport program the equipment will be used for.*

How will the equipment increase sport opportunities for people with disabilities?*

Program Dates

Start Date:*

(dd/mm/yyyy)

End Date:*

(dd/mm/yyyy)

Number of Weeks*

Program Times*

Location(s)*

Which communities/towns have participants that will benefit from the equipment/sport program?*

Indicate the age group(s) your program will be targeting? (check all that apply)*

Under 12
13-18
19-54
55+

Who is your target audience? (check all that apply)

Athletes with an intellectual disability
Athletes with a physical disability
Athletes who are blind or visually impaired
Athletes who are deaf or hard of hearing
Other: (please explain)

Other*

Will the program be led by a qualified coach or instructor?*

Yes
No

Estimated number of athletes involved in the program?*

Estimated number of coaches/instructors involved in the program?*

Estimated number of officials involved in the program?*

Will there be training, certification or skill development opportunities offered to coaches/instructors?*

Yes
No

Will there be training, certification or skill development opportunities offered to officials?*

Yes
No

Will there be training, certification or skill development opportunities offered to volunteers?*

Yes
No

Please explain your answer.*

Will you be partnering with any other group, community or organization to offer this program?*

Yes
No

Please explain your answer.*

How will the program be promoted?*

Will the program incorporate Sport Science education or presentations (Ex. nutrition, mental training, training/fitness programs, etc.)?*

Yes
No

Please explain your answer.*

Approved grant amounts may vary depending upon the number of applications received and the level of funding available. If the full grant amount requested is not approved, how will this impact the purchase of equipment and the sport program?*

FINANCIAL INFORMATION

Please outline all anticipated program revenues and expenses and ensure the budget is balanced.

Note: Financial documentation (receipts) for the program must be provided at the time of the follow-up report. Please refer to the Follow-up Requirements section of the guidelines for acceptable forms of financial documentation.

Revenues

Revenues	Amount

Expenses

Expenses	Amount

TOTAL SURPLUS (DEFICIT)

ADDITIONAL INFORMATION

(OPTIONAL)

Please attach any additional program information such as registration forms, brochures or advertisements.

Drop files here or

Max. file size: 32 MB, Max. files: 5.

APPLICATION CHECKLIST

Before submitting the application, we recommend your organization review the following checklist to ensure your application is ready for submission.

I have read the Adaptive Sport Equipment Grant Guidelines.
The application is being submitted prior to purchasing the equipment.
I have attached two quotes from equipment providers for the equipment. If less than two quotes are included, I provided an explanation.
The application is complete, signed and dated by the club/community organization (if applicable).
The application is complete, signed and dated by the PSO/MSO/District.

CLUB/COMMUNITY ORGANIZATION DECLARATION

consent 1*

I acknowledge that if this application is approved, I will be required to enter into an agreement with the PSO/MSO/District which will detail the terms and conditions of the grant.

consent 1*

On behalf of our organization, I hereby agree that the terms and conditions outlined in the guidelines will be adhered to and the information presented in this application is correct and true.

Club or Community Signing Authority

Name*

Title*

Date*

(dd/mm/yyyy)

After the club/community organization has completed the application form, please send the link to the PSO/MSO/District for their endorsement by clicking on the Save and send link to PSO/MSO/District at the bottom of the form. The PSO/MSO/District will then review and choose to endorse the application and submit it to Sask Sport.

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Adaptive Sport Equipment Grant Application Form

APPLICATION DEADLINES

PLEASE NOTE: If you are a PSO/MSO/District reviewing and endorsing an Adaptive Sport Equipment Grant Application Form, you will need to change the selection to “PSO/MSO/District Reviewing and Endorsing an Application Form” in order to submit the form to Sask Sport.

CONTACT INFORMATION

FUNDING INFORMATION

EQUIPMENT INFORMATION

ADAPTIVE SPORT EQUIPMENT QUOTATION INFORMATION

PROGRAM INFORMATION

FINANCIAL INFORMATION

ADDITIONAL INFORMATION

APPLICATION CHECKLIST

CLUB/COMMUNITY ORGANIZATION DECLARATION

PSO/MSO/DISTRICT DECLARATION