1st Reading_________________

2ND Reading________________
Approved________________
Not Approved________________
NEW PROJECT PROPOSAL
Directions: Please complete the following information. Use additional sheets if necessary.

Implementing Agency: _____________________________ Name of

Proposal:____________________________________

Contact Person: _______________________________Title:

____________________________Phone_____________________

Type of Program (Please check one): Prevention/Education ( ) Treatment ( ) Justice ( )

Starting Date: _______________ Ending Date: ___________________

Target Population:___________________ Estimate # of Persons Served or

Impacted:_____________________________

Brief description of
program:________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Goals and Objectives for Program:

Goal
1:____________________________________________________________________________________________________
Objective
1:1_______________________________________________________________________________________
Objective
2:1_______________________________________________________________________________________
Goal
2:____________________________________________________________________________________________________
Objective
1:2_______________________________________________________________________________________
Objective
2:2_______________________________________________________________________________________
Goal
3:____________________________________________________________________________________________________
Objective
1:3_______________________________________________________________________________________
Objective
2:3_______________________________________________________________________________________
Steps for Implementation of Program:
1._________________________________________________________________________________________________________
2._________________________________________________________________________________________________________
3._________________________________________________________________________________________________________
4._________________________________________________________________________________________________________

Amount Requested:____________________

Implementing Agency Signature:

I, the undersigned, affirm that I am of, and support, this proposal for funding of this program from
the State Drug-Free Communities Fund.

Signature Title Date

_________________________________________________________________________________________
_

To: All Applicants

From: Citizens for a Drug Free Ohio County

The Citizens for a Drug Free Ohio County is interested in the needs of your
organization. The County Commissioners are responsible for the allocation decisions of
the Drug-Free Communities Funds, with the County Council making the actual
appropriations to the Citizens for Ohio County Drug Free Community Committee.
These funds can only be used to carry out recommended actions contained in a
comprehensive drug-free communities plan approved by the Commission for a Drug-
Free Indiana. At least 25% of these funds must go to each of the following three service
areas:

Prevention and education

Intervention and treatment
Criminal Justice

Funds from the Prevention and Education service area will be limited to $1000.00 per
grant request.

The following are the guidelines for distribution of local funds.

A. Goals for proposed program must be established.
B. Objectives must be measurable and have a completion date attached to them
(ie. Make 50 flyers by 1/16/02).
C. Goals and objectives must satisfy requirements of the Governor’s Commission
for a Drug Free Community.
D. Methods for implementation must be listed.
E. Those requesting funds for the organization must attend 6 meetings per year.
F. A written evaluation and oral presentation is required within 2 months of the
completion date of program.
G. Additional funding will not be provided unless previous grants’ obligations
have been fulfilled.
 Citizens for a Drug-Free Ohio County
121 South High Street
Rising Sun, IN 47040

Evaluation Report
Implementing Agency: __________________________ Project Title:
____________________________

Contact Person: __________________________Title: ___________________Phone:

________________

Date of Written Report: ___________________ Date of Oral presentation:

_____________________

Type of Program: Prevention/Education ( ) Treatment ( ) Justice ( )

Amount Requested:____________________ Amount Spent:___________________

Starting Date:__________________ Ending Date:____________________

Program Description:

Goals and Objectives of Program:

To what degree did you accomplish your established goals and objectives?
Did you experience any barriers that kept you from meeting your goals?

Population Served (indicate numbers)

Check all special target populations reached:

__________Parents __________Elderly
__________High-risk youth __________Minorities
__________Economically Disadvantaged __________Other-specify:__________

Children: to grade 6____________ Young Adults__________________

Children: Middle/Jr. High_______ Adults 26 to 54_______________

Children: High School___________ Senior Adults 55 up___________

PLEASE ATTACH CLIPPINGS, FLYERS, BROCHURES, ETC. RELEVANT TO THE

PROJECT.