Official Languages Health Program Micro-funding Grants Application Form

Important

Please ensure that you answer all questions so that we can assess your request for funding in a timely manner. Incomplete applications will not be considered.

Once completed, this form must be sent by email to: hc.olcdb-baclo.sc@canada.ca

Part A - Contact Information

• First Name:
• Last Name:
• Address:
• City:
• Province/Territory:
• Postal Code:
• Telephone Number:
• Email Address:
• If applying on behalf of a non-profit organization, please provide the name of that organization:

For individual applicants:

• Please identify if you are:
  • Canadian citizen
  • Permanent resident
• Please select your age:
  • 16 - 25
  • 26 - 45
  • 46 - 64
  • 65 +
• Please select your sex:
  • Female
  • Male
  • Other

Part B - Project Information Project Title:

Project Start Date (DD-MM-YYYY):

Project End Date (DD-MM-YYYY):

Which official language minority community will your project target

• Anglophones in Quebec
• Francophones outside Quebec
• Both

Please describe your project activities:

In 250 words or less, include information on the goals of the project and description of the activities you will undertake, how your project will have a positive impact on its target audience, and how your project has the potential to create Compassionate Communities in official language minority communities.

Identify your target audience (select all that apply):

• Youth
• Seniors
• Parents / Caregivers
• Teachers
• Health Care Professionals
• General Population
• LGBTQ2+
• Indigenous
• Other (please specify)

Expected number of people who will benefit from your proposed project:

Please describe how you will promote your project's activities to encourage participation and/or spread the word:

Using 1-2 sentences, or bullet points, please describe how you intend to promote your project, for example: through various social media channels, such as Facebook, Twitter, LinkedIn, etc. or through word of mouth, email, posters, etc.

Please describe how you will spend any funding for your project.

Using bullet points, provide a list of project items with their anticipated costs, such as materials and supplies, printing, speaker fees, room bookings, communication and dissemination, equipment rental, etc.

Part C - Declaration, Acknowledgement and Agreement

(For your application to be considered for funding, all boxes must be checked)

On behalf of myself or the non-profit organization undertaking the project activities:

I declare that:

• The information in the application is true, accurate, and complete.
• I have or will obtain all the authorities, including permits, licenses and consents, necessary to undertake the proposed project and, if requested, will provide them to Health Canada. This includes permission from the owner to post, publish, reproduce or translate materials belonging to a third party, and permission from the subject (or parents, in the case of a minor) to post or publish photos or videos.
• No public servant or holder of public office, past or present, will derive a direct benefit from funding received to undertake the project activities described in this Application.
• Project activities will be undertaken in compliance with all applicable statutes, regulations, orders, standards and guidelines.

I acknowledge that:

• The submission of this Application does not constitute a commitment on the part of Health Canada to award funding.
• Even if my project is eligible, funding is not guaranteed. It is possible that the approved funding may be less than the amount requested.
• If for any reason I cannot be reached through the contact information provided, or I do not respond within seven (7) days of being contacted, or if there is any reason I can no longer participate, my application will be declared null and void, and another applicant will be selected.

Should my application be approved, I acknowledge and agree that:

• I will be required to provide banking information.
• This signed application and Health Canada's response by email indicating that funding was approved, will constitute the funding agreement, effective as of the date of the email indicating that funding was approved.
• This agreement does not create a partnership, agency or joint venture and I shall not represent myself as an agent, partner or employee of Health Canada in carrying out the project activities described in this Application.
• These funds may only be used for their intended purpose. Projects may be subject to random audits. Submitting false or misleading information, or misuse of funds may result in the recovery of funds and/or ineligibility for future project funding.
• I will share the results of my project on social media using the hashtag #CompassionateOLMCs, #Canada, #OLMC, #HealthCanada and/or #OLHP.
• I will send evidence of social media activity to hc.olcdb-baclo.sc@canada.ca within two (2) weeks of the publication of the project's results on social media. Results should include details on what the project is about, when it took place, how many individuals and/or groups participated/benefited, and what the outcome was, including any successes or failures.
• The Government of Canada, its officers, servants, employees and agents are not liable for any claim or cause of action arising from any injury or death to any person, or any damage or destruction of property, sustained in carrying out the project activities described in this Application. As the Applicant, I understand that I am responsible for and shall indemnify Health Canada, its officers, servants, employees or agents, from and against all actions, claims, demands, and losses that arise in relation to the Project.
• I will not use or authorize others to use the name, symbols or marks of Health Canada/the Government of Canada, in any way that could be interpreted as expressed or implied endorsement of the project by Health Canada/the Government of Canada.

Part D - Privacy Notice

(For you application to be considered for funding, you must be check the box below)

I have read and understand the below privacy information.

• The personal information I provide is protected in accordance with the Privacy Act and collected under the authority of the Department of Health Act, Section 4.
• Health Canada requires my personal information in order to assess and make decisions regarding my micro-funding grant application.
• My personal information may also be used for processing payments and/or financial reporting.
• My personal information will be kept for a period of 6 years and then destroyed, in accordance with Health Canada's disposition authority.
• Failure to provide the requested information may prevent the processing and/or approval of my application.
• This personal information collection is described in Info Source, available online at infosource.gc.ca, Personal Information Bank PSU 931.
• My rights under the Privacy Act: I have the right to request access to and correction of my personal information. I also have the right to file a complaint with the Privacy Commissioner of Canada if I think my personal information has been handled improperly.

For more information, please contact the Official Languages Health Program at hc.olcdb-baclo.sc@canada.ca or for more information regarding privacy, the Privacy Management Division at hc.privacy-vie.privee.sc@canada.ca.

Part E - Signature of Applicant (individual or person authorized to sign on behalf of the non-profit organization or a minor).

• Signature:
  • Date:
• Parent/Guardian Signature (if applicant is a minor):
  • Date:

Thank you for your application. You will hear from Health Canada soon!