GRANT APPLICATION FORM

Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Applications must be postmarked by the
deadline date to be eligible.
PLEASE NOTE: All questions MUST be answered or your application will be considered
incomplete and ineligible for funding.

APPLICANT INFORMATION
Organization Name:

Regina Palliative Care Incorporated

Primary Contact: Karen Mason Position: Manager of Operations and Fundraising

Contact Email:
Tel:

Karen@rpci.org

306-523-2780

Mailing Address:

Cell:

Website: www.rpci.org
306-747-8275 Fax:

306-766-2508

700B-4400, 4th Avenue

(Town/City/Province)

Regina SK

(Postal Code)

S4T 0H8

GRANT REQUESTED
Name of project:

Creating Capacity for Grief (CCFG)

Total Cost of Project: $ 252,920

Grant Request to CIF: $
50, 000
NOTE: Maximum Local grants are $25,000, Provincial grants $50,000. Maximum
summer Local grants are $5,000, Summer Provincial $10,000. Submissions for two
Annual grants during same calendar year must be for different projects.
Start Date (M/D/Y)

January 2, 2014

End Date (M/D/Y) December 31, 2014

Select deadline, delivery area and type of grant request:

Deadline
April 1st
X October 1st
February 1st (Summer grant only)

Delivery area
X Provincial
Local

Type
X Annual
Summer

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Community Grant Program APPLICATION
Indicate the RIC Region(s) where your project will be delivered
(View map: www.education.gov.sk.ca/ricregionurbmun )
Northern
West Central
South Central

Northwest
Saskatoon
Southwest

Prince Albert
Southeast
Regina

Northeast
X Provincial

ELIGIBILITY
Describe your organization:
X Incorporated Saskatchewan nonprofit

Nonprofit #:

BN119114221RR0001

Unincorporated community group endorsed by an eligible organization

NOTE: Endorsing organizations may be Saskatchewan nonprofits, municipalities, health
regions, schools or school divisions that agree to receive, administer and account for CIF
grants on behalf of your group. The Declaration of Endorsement form (Page 8) must be
completed and provided with the application.

DECLARATION BY APPLICANT
I declare the information contained in this application and supporting documents is true
and accurate.
Name of Organization: (print)

Regina Palliative Care Incorporated (RPCI)

Official Representative:
Name:

Karen Mason

Position:

Manager of Operations and Fundraising

Signature of Authorized Representative (on behalf of Organization):

Karen Mason
Date:
(M/D/Y)

September 30, 2013

Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.

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Community Grant Program APPLICATION

PROJECT
1.1 Priority Areas.
Identify the priority area(s) to be addressed by your project.
Primary
Additional
(Check one)

(Check all that apply)

Prevention and early intervention projects addressing

family violence, social services, health or justice-related issues

Community-led projects that address the needs of children

and youth

Aboriginal inclusion and projects that benefit urban Aboriginal

people

Youth leadership development and community involvement

Other. Please indicate:

Reduction of barriers to participation in programs

and activities
.

1.2 Identify the focus of activities involved in your project check all that apply.

Accessibility for the disabled

After school programming

Arts and culture

Early childhood development

Family violence
X
Health and wellness

Crime prevention

Newcomers to Canada
X
Organizational capacity building

Physical activity

Social services

Sport and recreation

School-based programming
X
Aboriginal inclusion

Volunteerism

Youth engagement/
Leadership.
1.3 Select the audiences who will benefit from your project check all that apply.

Children 0 5 years
X
Children 6 11 years
X
Teens 12 16 years
X
Youth 17 25
X
Adults

Older adults (55 +)

X
First Nations

Mtis

Newcomers to Canada

Individuals with disabilities.

Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.

4
Community Grant Program APPLICATION
2. Project Summary.
RPCI will launch its Creating Capacity for Grief (CCFG) Project in January 2014.
CCFG has two portions. The first portion will increase professionals knowledge of
childhood grief through delivering two-day conferences about Grief, Trauma, and the
needs of Grieving Children. Participants will include therapists, counselors, and local
caregivers. RPCI has received requests from health region officials and service providers
for grief and trauma training specific to childhood populations. A scan of available
training has confirmed a gap in training exists. Four Health Regions and Three Tribal
Councils have indicated they will encourage employee participation to attend our
conferences.
Conferences will be delivered over a two-year time frame, and revenues raised
will fund a Full Time Program Manager. Responsibilities of this position will include
delivery of conferences, building relationship with stakeholders, camp programing,
training camp facilitators, and program evaluation. In the second year the Program
Manager will act as a resource to local champions who will be running camps, deliver
conferences, relationship building, and continue program evaluation. This person will
work in conjunction with a Cultural Consultant to ensure culturally appropriate
programming.
The second portion of CCGC, which we are requesting funding for, will provide
four Relief From Grief weekend camps. Camps will be held near Regina, Saskatoon,
Prince Albert, and Moose Jaw. We will serve children aged 5 18 who have lost a family
member. Equal representation of Aboriginal youth, including Aboriginal urban youth,
will be sought through our partnerships with local Wellness Coordinators. A Cultural
Consultant will ensure culturally appropriate content and Elders will attend our camps.
Sadly, camps are necessary as many children experience the death of a family
member. Death of a loved one often has serious consequences for children. They may
experience developmental delays as well as long-term psychiatric, social, and
psychological struggles (McClatchey, Vonk, & Parardy, 2009, p. 19). For some people
complicated grief is experienced where sufferers display persistent yearning or longing
for the deceased, intrusive images or memories, avoidance behaviors, anger and
bitterness, survivor guilt, and inability to accept the death (Zuckoff, et al., 2006, p. 205).
When children are unable to resolve their grief they can be haunted by their loss for
many years.
One-way complicated grief can manifest itself is in addictions. As early as the
1980s there was mounting recognition of a possible connection between the addicted
persons loss of significant persons, unresolved grief and substance abuse (Denny &
Lee, 1984, p. 249). This connection between grief and addictions has been born out
over time and there is a long-recognized prominence of grief problems among people
with Substance Abuse Disorders (Zuckoff, et al., 2006, p. 209). The link between an
early, and at times devastating, loss of a loved one and the use of alcohol, drugs, or
gambling is evident.
Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.

5
Community Grant Program APPLICATION
Fortunately, we can help children and youth resolve their grief through
education and therapy. A camp setting normalizes the therapy experience and children
have opportunity to interact with others who have also experienced loss. Research
evaluating a grief camp found treatment as short as one weekend, which combines a
focus on both trauma and grief, may very well aid children in this process (McClatchey,
et al., 2008, p. 28). Camp participants will have opportunity to mourn their loss in a safe
supportive environment where trained therapists can assist them. Parents and
caregivers will also learn how to better support their child when they return home. The
needs of mourning children will be met, not only today, but also in the future.
3. Project Objectives.
Regina and Prince Albert have provided grief camps in the past. One camp is a
traditional week long camp with a grief component and the other is an overnight camp.
Neither camp follows a weekend long format, addresses trauma, has a family
component, or has a formal evaluation process. Both locations are eager to deliver a
camp based on our model.
Need for increased services are evident as in the past year 45 children remained
on waitlists and were unable to attend camp. In addition, three Tribal Councils and two
local communities asked for camps to be delivered in their areas.
Our objectives are:
100% of children attending camp will report a 50% reduction of symptoms or
severity of symptoms of grief.
100% of children attending camp will report a 50% reduction of symptoms or
severity of symptoms of trauma.
100% of parents/caregivers will report a 75% increase of knowledge of childhood
and grief and trauma.
100% of parents/caregivers will report increased confidence to help their child
cope with grief and trauma.
Therapists, Addiction counselors and local professionals will report a 50% self
reported increase of knowledge of childhood grief and trauma.
Therapists, Addiction counselors, and local professionals will report a 50% self
reported increase in grief and trauma specific therapeutic skills.
Anticipated Outcomes:
120 children and youth who have lost a family member will participate in camp
120 parents/caregivers for children will attend educational programing.
4 Local Champions will be trained to deliver manage future camps.
36 Professionals will be trained to facilitate camps.

Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.

6
Community Grant Program APPLICATION
4. Activities.
Local Champions will be recruited from Mental Health staff and trained to deliver
all aspects of a camp. Additional health region staff, Elders, and Clergy will be enlisted.
Promotional/referral packages will be distributed to Mental Health and Addictions staff,
Wellness Coordinators, Palliative Care wards, hospitals, school social workers, and local
clergy. The program manager will work with the local champion to screen participants
and ensure practical aspects of camp are addressed.
CCFG Program manager and the Cultural Consultant will provide a highly
competent team of local professionals with two days of training and preparation prior to
camp beginning. Teams will consist of a Local Champion, 3 Mental Health therapists, 2
Addictions Counselors, a cultural consultant, an Elder, a Clergy member, and psychiatric
nurse. Training will focus on grief, trauma, childhood grief, and specific treatment
modalities to be utilized in the camps.
Participants will be grouped by age as cabin mates and will travel through
therapeutic stations together. A combination of whole group and small group
educational, therapeutic, trust building, and play activities will be provided. Art and play
therapy techniques will be utilized and will be age appropriate. Programing on trauma
will include the trauma experience, trauma and loss reminders, posttraumatic
adversities, interplay of trauma and grief, and resumption of developmental
progression McClatchy, et al., 2008, p.20). Grief therapy will be based on the four tasks
of mourning identified by William Wolden: To Accept the Reality of the Loss, To Process
the Pain of Grief, To Adjust to a World Without the Deceased, and To Find an Enduring
Connection With the Deceased in the Midst of Embarking on a New Life ((Brown, 2013,
p. 10). Campfires and games will teach children how to use healthy activities to care for
themselves. Religious programming will not be provided; however Elders and Clergy
members will be available to address any spiritual needs that arise.
On the last day, parents and caregivers will arrive and attend program parallel to
their child. Educational programming on grief and trauma in children with an emphasis
on how to support grieving children and parental self-care will be provided. A balloon
release will serve as a joint closing ceremony.
5. Community Benefits.
Grieving children will receive services today, and the communities ability to
meet the needs of grieving children tomorrow will be increased. Communities will be
left with the practical and therapeutic knowledge required to deliver grief camps.
Evaluation processes will increase the wider therapeutic communities knowledge of
how to effectively treat childhood grief.
6. Sustainability.
Once the efficacy of RFG Camps are demonstrated core funding for camps will be
sought from participating Health Regions. PAPHR funds a current grief camp and has
Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.

7
Community Grant Program APPLICATION
agreed to fund our model once evaluation demonstrates effectiveness. Alternatively,
grief and trauma have been identified as key issues for Aboriginal youth, and various
tribal councils have expressed interest in funding camps for children once they are
shown to be effective.
7. Partners.
RPCI has developed a number of strong partnerships. Greystone Managed
Investments provides funding for the Greystone Bereavement Center and have agreed
to fund office space and operating costs for the CCFG Program Manager. Prince Albert
Grand Council has committed to provide a Cultural Consultant to assist with program
development and attend camps. Prince Albert Parkland Health Region, Saskatoon
Health Region, and Five Hills Health Region have committed to provide staff to deliver
camps. Prince Albert Grand Council, Saskatoon Tribal Council, and Five Hills QuAppelle
Valley Tribal Council have expressed their intent encourage staff to attend CCFG
Conferences and to have Wellness
Coordinators refer children to camps.
Please see appendix B for letters of support from each Health Region and Tribal
Council.
8. Volunteer Contributions.
Due to the complexity of the services provided professional staff will deliver
programming. However, Clergy members and Elders will be asked to volunteer their
time in exchange for an honorarium of $150/day. It is anticipated volunteers in these
roles will provide 320 hours of services.
9. Evaluation.
The Childhood Traumatic Grief Symptom Scale and the Extended Grief Inventory
for Children tool will be utilized to measure change in participants. Both tools use selfreports to assess symptoms in Children. Tests will be completed prior to leaving for
camp to determine symptoms experienced for 30 days prior to attend camp. Tests will
be retaken at the end of camp, and two weeks post camp.
Parents will complete self-reported evaluations of their knowledge of childhood
grief and trauma and their ability to support their child to cope with grief. Team
members will utilize self-reported evaluations to assess their levels of knowledge and
therapeutic skills. Parent and Team evaluations will be completed prior to leaving for
camp, immediately upon return, and 3 months post camp.
Data will be compiled and evaluated by the Creating Capacity for Grief Program
Manager. Results will be disseminated in the form of a report that will be shared with
local champions of health regions and tribal councils. The report will be placed on the
RPCI website and become part of our library of resources.

Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.

8
Community Grant Program APPLICATION
10. Recognition of the CIF.
The Community Initiatives Fund name and logo on all promotional materials,
listed on our website as a major contributor, and will be placed on a silver butterfly and
hung on our Garden of Giving wall in the lobby of RCPI if a grant is awarded.

BUDGET and FUNDING

Identify all budgeted revenue and expenses relating to your project. Note both Eligible
and Ineligible expenses as stated in the Community Grant Program Guidelines for Grant
Applicants. On page 6, list all Project Supplies and Other Project-Related Expenses in the
appropriate charts, total and include each amount in the Expenses section, below. For
each Expense item, state the amount requested from the CIF in the CIF REQUEST
column. Retain all project-related receipts for submission with your Final Project Report.

Budget for Relief From Grief Camp

TOTAL PROJECT
BUDGET

Requested

Confirmed

Income
Other Funding Sources:
Provincial government
Other (Prince Albert Grand Council)
CIF Funding Request

54,880
6,720
$ 50,000

Total Income

$111,600

TOTAL PROJECT
BUDGET

CIF REQUEST

Expenses
Project Staff Salaries

$ 61600

$0

Project Staff Benefits

$0

$0

Project Supplies (Refer chart on page 6)

$10,000

$ 10000

Other Project-Related Expenses

$25000

$ 25000

$15000

$15000

(Refer chart on page 6)

Overhead (maximum 20% of CIF Request)

Total Project Expenditures
Community Initiatives Fund
(Total Amount Requested)

$111,600
$50000

Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.

9
Community Grant Program APPLICATION

Project Supplies Addendum to Budget.

List all supplies and include total estimated cost in Budget, page 5.
Supply
Estimated Cost
Craft supplies for Therapy
10000
Food
19400
TOTAL:

$ 29400

Other Project-Related Expenses Addendum to Budget.

List all other expenses and include total estimated cost in Budget, page 5.
Other Expenses
Estimated Cost
$150/day honoraria - Elder
2000
Camp rentals
15000
Client/Family Transportation
3600
TOTAL:

$ 20,600

Contributions: Goods and Services.

Indicate contributions, other than financial, to your project and include approximate
value. (Include donation of supplies, professional services.)
Name of Contributor
Prince Albert Parkland Health
Region, Five Hills Health Region,
Saskatoon Health Region, Regina
QuAppelle Health Region

Contribution
In Kind contribution of
Mental Health and
Addictions Staff member

Approximate Value
54,880

Prince Albert Grand Council

In Kind contribution of
Cultural Consultant
(Time spent at camp)

6,720

Please see Total Creating Capacity for Grief Budget in appendix A.

Mail two copies of this application form to: Grants Administrator, Community Initiatives
Fund, 1870 Lorne Street, Regina, SK S4P 2L7. Postmark on or before Program deadline.