Page 1GRANT APPLICATION FORM Forms are in compliance with the National Standard for Arts Information ExchangeGrant Application OrganizationApplicant IndividualMailing AddressPhysical AddressIsland ID: 858973
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1 1st District Page 1GRANT APPLICATION FOR
1st District Page 1GRANT APPLICATION FORM Forms are in compliance with the National Standard for Arts Information Exchange Grant Application - Organization Applicant - Individual Mailing Address Physical Address Island/State/Zip Code Contact Person (name) Title Address (if other than above) Daytime Phone/Home/Cell Phone E-mail Address Applicant status (check one) 01 Individual 05 Government 02 Non-Profit 99 None of the above Tax ID or SS # Project Title Congressional District of Applicant For VICA Staff Use Only Application # _______________________________ Narrative Description Project: Amount of Request $___________________________________________ Applicant's signature Date CATEGORY(check 19. 10. 11.Cinema-theater 12. 13. 17. 16. 15. 14. 05. 06. 08 09. 04. 03. 02. 01. 20. 21. 22. 30. 29. 28. 27. 26. 24. 23. 35. 32. 31. 36. 37. 38. 99. 49. 48. 47. 1. 2.
2 3. 4. 5. 6. Applicant ) Applicant Non-A
3. 4. 5. 6. Applicant ) Applicant Non-Arts/Non-Humanities Multidisciplinary Humanities Folklife/Traditional Interdisciplinary Literature Media Photography Crafts Design Visual Theater Music Opera/Music Dance 01. 02. 03. 03. 04. 05. 06. 07. 08. 12. 09. A. C. B. D. 10. 11. 13. 14. 15. More Specific Scheduled Location(s) Individuals Theinparticipantsfigures. A. I U R P W K H B. C. Discipline:Identify activities(check Page Page 3Type of Activity: describe activity which best describes project (check correct item) 01. 50% or more of this project's activities are arts 99. None of this project involves arts education. 02. Less than 50% of this project's activities are P. Presenting/Touring Y. Youth at Risk A. Accessibility T. Technology I. International 02. Audience services 04. Creation of a work of Art 05. Concert/Performance/Reading 06. Exhi
3 bition 08. Fair/Festival 09. Identificat
bition 08. Fair/Festival 09. Identification/Documentation 11. General Operating Support 12. Art instruction: (include lessons, classes, 13. Marketing 14. Professional support - Administrative 15. Professional support - Artistic 16. Recording/Filming/Taping 17. Publication (e.g., manuals, books, newsletters) 19. Research/planning: include program 20. School residency: artists activities in an 21. Other Residency: artists primarily in other than 22. Seminar/Conference 25. Apprenticeship 29. Professional development/training: activities 30. Student assessment: the measurement of 31. Curriculum development/Training: includes 35. Website/internet development 36. Broadcasting 99. None of the aboveand other means used to teach knowledgeevaluation, strategic planning, and establishingevaluation, strategic planning, and establishingpartnerships/collaborations between ag
4 encies.partnerships/collaborations betwe
encies.partnerships/collaborations between agencies.an educational institution.of and/or skills in arts.which enhance artistic career advancement.student profress toward learning objectives.design, implementation and distribution ofinstruction materialArts in Educationeducation directed to:A. K-12 studentsB. Higher education studentsC. Pre-kindergarten childrenD. Adult-learners (including teachers and artists)arts education directed to:A. K-12 studentsB. Higher education studentsC. Pre-kindergarten childrenD. Adult-learners (including teachers and artists)Project Descriptors (mark all that apply) * Grantee RaceIndividual or OrganizationsOrganizations - select one which best describes your staff, board or membership: Individuals - select one or any N. 50% or more American Indian/Alaska Native A. 50% or more Asian P. 50% or more Native Hawaiian/Pacific Islander
5 B. 50% or more Black/African American H
B. 50% or more Black/African American H. 50% or more Hispanic/Latino W. 50% or more White 99. No single group listed along compromises50% or more of staff or board or membershp Project Race: Project clearly emphasizes the tradition or culture of one particular race: N. American Indian/Alaska Native A. Asian P. Native Hawaiian/Pacific Islander B. Black. non-Hispanic H. Hispanic W. White, not Hispanic 99. No single group* Racial Identification information is being used for compliance with the Civil Rights Act only. Page VIRGIN Detailed Date: Organization/Individual: Part EXPENSES DOLLAR SOURCE 1.2.3.4.5.6. TOTAL 1.2.3.4.5.6. 7. TOTAL INCOME Part In-KindIn-KindIn-KindIn-KindIn-KindIn-KindTOTAL In-KindservicesIn-Kind. IN-KIND Page 5 PART I - BUDGET SUMMARY1. Admissions 2. Dues, membership fees, etc 3. Other Revenues a. Catalogue sales
6 b. Program advertising space c. G
b. Program advertising space c. Gift shop income d. Concessions f. Other 5. Foundation SupportApplicant's Matching Funds...6. Other Support a. Government Support b. Other Federal c. Local/Regional 7. Applicant Cash 8. Amount of VICA request TOTAL CASH INCOME $ Administrative - (for this project). Executive & Supervisory Staff Program Directors Managing Directors Clerical Staff Bookkeeper Maintenance& Security Staff Other (Identify)Expenses to Applicant PART II - BUDGET BREAKDOWNFunded by VICAFunded by other Sources SUBTOTAL1. PERSONNEL (If more than one category applies, list under category in which the majority of times allocated).$$2. PERSONNEL - ARTISTIC (for this project) Directors Musicians Actors Dancers Other (Identify) SUBTOTAL$$3. SPACE RENTAL - EXPENSES (for this project)Performance Hall Theater Rehearsal
7 Space Gallery SUBTOTAL$$ Page 6 PART II
Space Gallery SUBTOTAL$$ Page 6 PART II - BUDGET BREAKDOWN continued4. TRAVEL COSTS (directly identified with this project)Hotel Ground Transportation Air Transportation Ferry Boat Transportation Other (Identify) SUBTOTAL$$5. MARKETING COSTS (directly identified with this project)Newspaper Radio/TV Printing-Brochures, flyers, books, etc. Publicity, Advertising Website Design Other (Identify) SUBTOTAL$$ Scripts, scores Supplies/Materials Set & Props Equipment Rental Pressing of CDs Registration Fee (conferences, etc.) Shipping & Hauling SUBTOTAL$$ 6. REMAINING OPERATING EXPENSES (directly identified with this project) TOTAL PROJECT EXPENSES $$ Page 7 PROJECT BUDGET SUMMARY PAGE LIST ALL ITEMS PAID BY OTHER SOURCES $ $ $ $ $ $TOTAL LIST ALL ITEMS AND DOLLAR VALUE OF IN-KIND SERVICES $ $ $ $ $ $TOTAL LIST ALL ITEMS TO BE PAID BY VICA $ $ $ $ $ $Signature DateTOT