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“Give Burns The Boot”®
Chesney Fallen Firefighters Memorial Grant
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Youth Firesetter Intervention Program
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Staff
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Newsletters
Contact Us
Get Involved
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Support “Give Burns The Boot”®
Donate
Survivor Services
Belli Memorial Endowment and Scholarship
Camps & Retreats
Summer Camp Oo-U-La
Burn Survivors Family Weekend
Young Adult Burn Survivor Retreat
Phoenix Society’s World Burn Congress Sponsorship
Other Services
Sensitivity & Awareness Program
Social Re-Integration
Peer Support
Resources and Helpful Links
Fire Service
“Give Burns The Boot”®
Chesney Fallen Firefighters Memorial Grant
Prevention Partnerships
Fire and Life Safety Blitz Program
Children After the Fire
Youth Firesetter Intervention Program
Firefighter Support
Firefighter Recognition Luncheon
Resources and Helpful Links
About Us
Our Mission
Board of Directors
Staff
Financials
Articles
Newsletters
Contact Us
Get Involved
Donate Today
Business Sponsorship
Event Calendar
Project R.E.A.C.H
Support “Give Burns The Boot”®
Donate
2019 Chesney Fallen Firefighters Memorial Grant Program Application
Chesney Fallen Firefighters Memorial Grant Program Application 2019
Step 1 of 7
14%
Grant Application
Please complete all items. Questions with an asterisk (*) require an answer. IMPORTANT NOTE: This application must be completed in its entirety at the time of submission and is unable to be saved to work on as you go. You are encouraged to download the PDF file,"INFORMATION NEEDED FOR GRANT APPLICATION," to work on your answers in a saved document and then copy/paste your responses into the online application.
Fire Chief/Fire Department Information (NOTE: The Fire Chief is required to sign the grant contract for the application to be considered complete.)
Name (Fire Chief):
*
First
Last
Title:
*
Name of Fire Department applying for grant:
*
Fire Department Compliance Number:
*
Note: Compliance numbers can be obtained from the Georgia Firefighters Standards and Training Council. Applications without compliance numbers will not be considered.
Department Type
*
Paid
Volunteer
Combination
What is the size of your fire department (i.e. staffing numbers)?
*
What is the population of the departments jurisdiction?
*
What is the per capita income of the departments jurisdiction?
*
Mailing Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Implementing Personnel Information (NOTE: This is the person who will be responsible for implementing grant funds if awarded.)
Name (Implementing Personnel):
*
First
Last
Title:
*
Name of Fire Department:
*
Mailing Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Daytime Phone Number:
*
Email:
*
Note: This email address will be used for all communication regarding the grant, including confirmation of online application submission.
Select relevant professional qualifications of the person responsible for implementing the program/project (listed above). Check all that apply.
*
Fire and Life Safety Educator
Firefighter
Active in Fire and Life Safety Education (current professional responsibilities)
Youth Firesetter Intervention Specialist
Other
If other, list qualifications:
*
Fire Department Information
What is the prevention/education budget for your fire department?
*
Describe your department’s experience and/or achievements with fire safety and burn prevention activities by briefly describing the mission, goal and major accomplishments of your fire safety education department.
*
What other agencies/departments does your department work with other to provide fire safety and burn prevention education (e.g. other Fire Departments, Schools, Safe Kids, EMS, Law Enforcement, Insurance Companies)?
*
Has your department received CFFM Grant funding in the past?
*
Yes
No
If you are unsure about receipt of funds please contact the GFBF office.
If yes, how and for what purpose were funds utilized?
*
Is the program/project still active?
*
Yes
No
If no, explain:
*
What Georgia Firefighters Burn Foundation activities has your department been involved in and/or supported, even if personnel did not physically attend (past and current)? Check all that apply.
*
Give Burns the Boot®
Project REACH
Burn Camp
Young Adult Retreat
Family Weekend
World Burn Congress
Fire and Life Safety Program
Holiday Decorating/Party at JMS or Grady Burn Centers
Other
If other, list activities:
*
Program/Project Specific Information
In as much detail as possible provide a description of your program/project that these funds would support including your target audience. Be specific.
*
Is this a new or existing program/project in your department?
*
New
Existing
Explain the need for the program/project.
*
Describe how you will evaluate your program/project. Be specific and consider a variety of methods.
*
Please refer to the resources provided under "Helpful Links for Grant Writing Resources" just below "Application and Supporting Documents" on the Chesney page.
Provide a schedule with a specified time frame for your program/project completion.
*
List other groups/agencies who partner with you on this program. If you are not partnering with anyone else, skip this section.
Name One of Group/Agency partnership:
First
Last
Address One of Group/Agency partnership:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name Two of Group/Agency partnership:
First
Last
Address Two of Group/Agency partnership:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name Three of Group/Agency partnership:
First
Last
Address Three of Group/Agency partnership:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name Four of Group/Agency partnership:
First
Last
Address Four of Group/Agency partnership:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Outreach and Cost
If your department is awarded the grant, describe plans for promotional outreach regarding receipt of grant funds from the GFBF for your initiative.
*
What is the total cost of the program?
*
NOTE: The budgetary worksheet found on the website must be submitted for your application to be complete.
What is the total amount requested from the Georgia Firefighters Burn Foundation through the Chesney Fallen Firefighters Memorial Grant Program (total may not exceed $3,000)?
*
If the total cost exceeds $3,000, demonstrate resources are available to complete program/project. If not applicable, please type "N/A".
*
How did you learn about the Chesney Grant? Please check all that apply.
*
GFBF Website
GFBF Facebook Page
Internet Search
Fire Department
Fire Marshal's Office
Georgia Public Safety Educators Association
Georgia Public Safety Training Center
Daily Dispatch
Word of Mouth
Other
If other, list where you learned about the grant:
*
File Upload (Optional)
You have the option to upload the required files for the application instead of mailing hard copies if you would like. Please only send PDF, Word, Excel, or JPEG files. Maximum file size is 128MB.
Drop files here or