Please read all instructions and requirements before proceeding to the form. You must have a current PHW Collaborative Pledge on file. The applicant must be a faith community. The faith community must be predominantly of color/ BIPOC (Black and Brown, Indigenous, and People of Color). If awarded, the faith community must complete a PHW Mental Health Inclusion Plan. If you need assistance completing the form, please don't hesitate to contact the Associate Director, Partners in Health and Wholeness, Mental Health Advocacy, Rev. Jessica Stokes jessica@ncchurches.org Attention You are not able to save and come back to the Pledge form. We recommend you print this document to prepare your responses BEFORE entering them on this form. We also highly recommend you save your answers on a separate document as you fill out the form so that you do not lose your responses if the form closes for any reason. A copy of your pledge submission will be sent to you and your faith leader. ONCE YOU HAVE SUCCESSFULLY SUBMITTED THE FORM, PLEASE CHECK TO MAKE SURE YOU HAVE RECEIVED A CONFIRMATION EMAIL All applications that include a request for grant funds that require in-person gatherings or other activities that could be affected by the COVID-19 virus, must include a Plan B in case of a worsening of the virus and/or a tightening of restrictions. For example: if your grant request includes in-person gatherings in an enclosed space, and the virus worsens or restrictions tighten, what will you do instead? If your grant request includes funds for children in school, but schools close, what will you do instead? Including this information in the grant request will allow us to review in a timely manner and not hold up your application while we follow up with you. Form Submission Guidelines When filling out the form, please type every name out fully with no abbreviations including congregation names, health lead names, and faith leader names. Example: St. Maria's United Methodist Church NOT: St Marias UMC As we continue to expand our network, we hope you will continue to include as much detail as possible in the PHW forms. We ask Health Leads to always answer the 5 W's: Who, What, When, Where, and Why? * Items with this symbol are required information General Information Congregation Faith Community Name Mailing Address Street Address City Postal Code Country * - Select -United States State/Province North Carolina County Physical Address Street Address City Postal Code State/Province Phone Number Country 2 * - Select -United States Church Health Lead Contact Information Title - None -Ald.Asm.Assembly MemberAssemblymanAssemblywomanBishopBorough PresidentBrBrotherCapt.CoachCommissionerComptrollerCongressmanCongresswomanCouncil MemberCouncilmanCouncilwomanDeaconDeanDet.Dr.FatherFr.Gov.GovernorHon.ImamLt. GovernorMayorMinisterMonsignorMr.Mr. & Mrs.Mr. & Ms.Mrs.Mrs. & Mr.Ms.Ms. & Mr.Msgr.PastorPresidentProf.ProfessorRabbiRep.RepresentativeRev.Rev. CanonRev. DeaconRev. Dr.ReverendSen.SenatorSgtSisterSr.Sra.The HonorableThe VenerableDr. and Mr.Dr. and Ms.ElderMr. and Mrs.Mr. and Ms.Ms. and Mr.Rev Dr.The Rev.The Rev. & Mr.The Rev. DeaconThe Rev. Dr.The ReverendThe Right. Rev.The Rt. Rev.Drs.Dr. and Mrs.Dr. & Rev.The Rev. and MsMissThe Rev. CanonMajorRev. Msgr.CanonRev.Rev.The Rev. Fr.The Rev. & Mrs.Bishop EmeritusPastorsRectorThe Rev. ElderThe Very Rev.ApostleProphetApostle Dr.Reverend Dr.RevsMinister Dr.ProphetessCo-PastorOverseerChaplainPastor, Rev.Dr. Rev.EldressPastor Dr.AbbotBishop Dr. First Name Middle Name Last Name Name Suffix - None -AIACPACRNPCSWDDSDPADPMDSWEsq.IIIIIIVJDJr.LFDLMSWLPCM.D.M.Div.MHSMPAMSWOFMOPPEPh.DRNRSMS.J.Sr.VVIVIIDVMPA,MPHRN, BSN, M.DivMSMA, RHRN MPHRN,PNRN, BSN Phone Number Email Faith Leader's Title and Contact Information Title - None -Ald.Asm.Assembly MemberAssemblymanAssemblywomanBishopBorough PresidentBrBrotherCapt.CoachCommissionerComptrollerCongressmanCongresswomanCouncil MemberCouncilmanCouncilwomanDeaconDeanDet.Dr.FatherFr.Gov.GovernorHon.ImamLt. GovernorMayorMinisterMonsignorMr.Mr. & Mrs.Mr. & Ms.Mrs.Mrs. & Mr.Ms.Ms. & Mr.Msgr.PastorPresidentProf.ProfessorRabbiRep.RepresentativeRev.Rev. CanonRev. DeaconRev. Dr.ReverendSen.SenatorSgtSisterSr.Sra.The HonorableThe VenerableDr. and Mr.Dr. and Ms.ElderMr. and Mrs.Mr. and Ms.Ms. and Mr.Rev Dr.The Rev.The Rev. & Mr.The Rev. DeaconThe Rev. Dr.The ReverendThe Right. Rev.The Rt. Rev.Drs.Dr. and Mrs.Dr. & Rev.The Rev. and MsMissThe Rev. CanonMajorRev. Msgr.CanonRev.Rev.The Rev. Fr.The Rev. & Mrs.Bishop EmeritusPastorsRectorThe Rev. ElderThe Very Rev.ApostleProphetApostle Dr.Reverend Dr.RevsMinister Dr.ProphetessCo-PastorOverseerChaplainPastor, Rev.Dr. Rev.EldressPastor Dr.AbbotBishop Dr. First Name Middle Name Last Name Name Suffix - None -AIACPACRNPCSWDDSDPADPMDSWEsq.IIIIIIVJDJr.LFDLMSWLPCM.D.M.Div.MHSMPAMSWOFMOPPEPh.DRNRSMS.J.Sr.VVIVIIDVMPA,MPHRN, BSN, M.DivMSMA, RHRN MPHRN,PNRN, BSN Email Has your faith community completed the Collaborative Pledge? * Yes No Denomination * - Select -Alliance BaptistAfrican Methodist EpiscopalAMEZApostolicBahaiBaptistChristian Methodist EpiscopalCooperative Baptist FellowshipDisciples of ChristEpiscopalEvangelical LutheranFree Will BaptistGeneral BaptistIslamicJewishLutheran - Missouri SynodMennoniteMetropolitan Community ChurchMissionary BaptistMoravianNon-DenominationalOtherPentecostal Holiness ChurchPresbyterianReformed ChurchReigious Society of FriendsRoman CatholicSeventh Day AdventistSouthern BaptistUMCUnited Church of ChristUnity Fellowship Church MovementNot affiliated with a denominationUnitarian UniversalistChurch of the Nazarene Denomination Other Racial and Ethnic Make-Up * - Select -Predominantly Bi/MultiracialPredominantly Black/African American/African DiasporaPredominantly International (not born in USA)Predominantly Latino/HispanicPredominantly Middle EasternIndigenousOtherPrefer not to disclose Details About Requested Funds COMMUNITY NEEDS: How has COVID-19 impacted mental health and emotional well-being in your faith community? What COVID-19 related effects on mental health and emotional well-being have you seen in the community at large? Please also name mental health concerns that you saw and experienced prior to COVID-19 that were made worse by the pandemic. * Of the congregational and community needs mentioned above, which will be met by this project, with regard to mental health? How will this project be sustained to continue meeting the intended needs? (Must be at least 10 sentences) * PROJECT OR PROGRAM: Please describe the mental health project or program for which the funds are being requested. Include details about who will be involved in the project or program and when and where the project or program will take place. This section should answer Who, What, When (including frequency for ongoing projects), and How. The more details you provide, the better we can understand your proposed project or program. (Must be at least 10 sentences) * Why is this project or program the most effective approach to address the congregational/community needs you identified above? * WORK PLAN AND TIMELINE: Provide a brief statement outlining the scope of work including the following: 1) Timeline of project/program 2) Who will complete each activity * All projects have unanticipated needs and require support. Please name your partners and resources that can provide support to your project. * FUNDING & BUDGET: Please list the itemized expenses associated with the project. Budgets should include specific amounts needed for each aspect of the project. If this request is part of a larger project, please indicate where other funds are being pursued. * Example "LivingWorks Faith" Suicide Prevention Training Class $166.62 per person (12)- $1999.44 Talkspace Therapy App vouchers 75.00 (50)- $3,750 Honorarium for Mental Health Speakers (3) at $600.00 each (lodging, gas, food)- $1800 *your costs may vary Total Amount Requested $ (projects must be between $5,000 to $10,000) $ EVALUATION: How will you measure the results of the project to determine impact? For example: include church policy changes that consider mental health needs for staff and attendees, a community-wide inclusive mental health pledge, establishing trauma-informed practices, ongoing staff trainings that address mental health needs, welcoming signage, highlight mental health in worship, host support groups, etc * RESULTS: What are the results you hope to achieve? Take into consideration where you are beginning and where you hope to go with your results. (Must be at least 5 sentences) * How will this project be sustained to continue meeting the intended needs? (Must be at least 10 sentences) * Understanding of Grant Eligibility I Understand Submit
