School Nurse and Pediatrician Partnership (SNAPP) Mini-Grant Program
2014 Grant Application


NOTE: Fields with an asterisk are required fields.

Pediatrician (Primary Contact)
Name *
Title *
Address *
City *
State *
ZIP Code *
Phone *
Fax
E-Mail *
AAP ID Number
AAP Chapter

COSH Member? * Yes No
(if no, you must apply for COSH membership before submitting this application)


School Nurse (Secondary Contact)
Name *
Title *
Address *
City *
State *
ZIP Code *
Phone *
Fax
E-Mail *

National Association of School Nurses (NASN) Member? * Yes No


Project Name *
Describe your community *
Type of School *

Student Population (check all that apply) *

     Early Childhood – Head Start, Pre-K
     Elementary – K-5
     Middle 6-8
     High School 9-12

Total Student Population *

% on Free/Reduced Lunch

Project Description (Describe the proposed project in 300 words or less) *

Is this a new project? * Yes No

If no, is this an expansion of an existing project? Yes No

If the proposed project is an expansion of a previously implemented one, please briefly describe the previous project (200 words or less)

Describe the role of the Pediatrician in the project *

Describe the role of the School Nurse in the project *

Provide a short biographical sketch of the Pediatrician (200 words or less) *

Provide a short biographical sketch of the School Nurse (200 words or less) *

Please describe 2-3 outcomes you hope this project will accomplish *

Please describe how you will communicate your project activities and outcomes to community stakeholders. (e.g., local AAP chapter, school board, school staff, etc) *
Budget
Please give line items with description, justification and estimated amount *
Budget Item Justification/Description Amount

Fiscal Agent: *
As a condition of this grant, grantees must identify a fiscal agent to manage the awarded funds. Fiscal agents must be a tax exempt organization under Section 501(c)(3) of the Internal Revenue Code or a government entity. Please see the Tips for Finding a Fiscal Agent for more information (PDF - will open in new window).

       I accept the above condition and responsibility for identifying a fiscal agent if awarded the requested funds.

Are there any other sources of funding for the project? * Yes No

If yes please list and describe