Community Stewardship Corps – 2020 Page 1 of 17 APPLICATION FORM COMMUNITY STEWARDSHIP CORPS 2020‐2021 Legal Name of Program Applicant: Address: City, State, Zip: State of Incorporation: Entity Type: Program Contact: Fiscal Contact: Name: Name: Email: Email: Phone: Phone: Any individual signing below hereby certifies they are an authorized representative of Applicant and that: 1. Applicant understands and accepts the requirements of this RFA. 2. Applicant acknowledges receipt of any and all Addenda to this RFA. 3. If awarded a Grant Agreement, Applicant agrees to perform the activities and meet the performance standards set forth in the final negotiated Grant Agreement. 4. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318. 5. Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding contracts, Applicant does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority‐owned business, a woman‐owned business, a business that a service‐disabled veteran owns or an emerging small business.
Transcript
Community Stewardship Corps – 2020
Page 1 of 17
APPLICATION FORM COMMUNITY STEWARDSHIP CORPS 2020‐2021
Legal Name of Program Applicant:
Address: City, State, Zip:
State of Incorporation: Entity Type:
Program Contact: Fiscal Contact:
Name: Name:
Email: Email:
Phone: Phone:
Any individual signing below hereby certifies they are an authorized representative of Applicant and that:
1. Applicant understands and accepts the requirements of this RFA.
2. Applicant acknowledges receipt of any and all Addenda to this RFA.
3. If awarded a Grant Agreement, Applicant agrees to perform the activities and meet the
performance standards set forth in the final negotiated Grant Agreement.
4. I have knowledge regarding Applicant’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Applicant is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.
5. Applicant does not discriminate in its employment practices with regard to race, creed, age,
religious affiliation, gender, disability, sexual orientation, national origin. When awarding contracts, Applicant does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority‐owned business, a woman‐owned business, a business that a service‐disabled veteran owns or an emerging small business.
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6. Applicant and Applicant’s employees, agents, and subcontractors are not included on:
A. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or
B. the government wide exclusions lists in the System for Award Management found at: https://www.sam.gov/portal/SAM/#1
7. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict
between the business or economic interests of Applicant, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFA. If any changes occur with respect to Applicant’s status regarding conflict of interest, Applicant shall promptly notify the State in writing.
8. Applicant certifies that all contents of the Application (including any other forms or
documentation, if required under this RFA) and this Applicant Information and Certification Sheet, are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.
9. Applicant understands that any statement or representation it makes, in response to this RFA,
if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Grant Agreement being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.
10. Applicant acknowledges these certifications are in addition to any certifications required in the
Grant Agreement at the time of Grant Agreement execution.
Please review the following assurances listed below:
1. Applicant agrees to follow all applicable labor laws, including but not limited to, federal and state tax laws and rules.
2. Background Checks are required for all staff & Crew Leaders having direct contact with
Corpsmembers. Any staff with sexual based convictions shall have no direct contact with
Corpsmembers.
3. Applicant has a transition plan in place to assist youth as they move out of the program.
4. Applicant agrees to develop safety, work site, orientation, education, and emergency plans in
compliance with state and federal law.
5. At least 75% of the youth served will meet Oregon Youth Corps’ definition of at-risk youth.
6. The crew will reflect the local community in the areas of gender, cultural, and ethnic mix.
7. Applicant understands that projects on private land must be preapproved by Oregon Youth Corps.
8. Applicant’s project will operate between August 1, 2020 and June 30, 2021.
9. Applicant will complete the required Oregon Youth Corps surveys at the end of the program.
10. No more than 10% of the grant award can be used for indirect costs.
11. All Crew Leaders will be first aid and CPR certified.
12. All Corpsmembers will be equipped with all appropriate Personal Protective Equipment (PPE)
during their program participation.
13. Crew Leaders will provide the appropriate level of supervision and instruction to ensure safety in work completion.
14. All tools and equipment used are relevant and the number of tools/pieces of equipment are
adequate for Corpsmembers to engage and safely complete the expected tasks.
Applicant acknowledges and assures each of the above listed items (#1-14) by checking this box:
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APPLICATION
All responses should support Oregon Youth Corps Mission and Vision:
Mission:
“Empowering youth by providing outdoor work and stewardship experiences throughout Oregon.”
Vision:
“Oregon’s at-risk youth are successful community members engaged in work, stewardship, and lifelong learning.”
Budget Information
Total grant requested (up to $20,000):
Number of youth to be served:
Total amount of Corpsmember hours:
Number of Crew Leaders:
Total amount of Crew Leader hours:
Budget Definitions/Tools
Direct Program Costs are those expenditures that directly support the project. Examples include but are
not limited to: salaries, tools, transportation of the crew, crew supplies, personal supplies (e.g. boots, gloves, etc.) or other costs that can be tied directly to the project.
Taxes/Fringe Costs are projected for Oregon Youth Corps grant – Examples of Taxes/Fringe costs may include: employer payroll taxes (FICA taxes, state unemployment taxes), health insurance, etc.
Administrative/Indirect Costs are those expenditures for activities that are necessary for the support of the program but are not directly tied to the program. Examples of these costs include but are not limited to: salary-related expenses, miscellaneous office supplies, costs incurred for grant reporting
requirements, accounting costs, etc.
Leverage is a financial commitment toward the costs of a project from a source other than the granting organization through cash and/or in-kind contribution. Leverage can be achieved by a commitment from the grantee or through various partnerships.
To help Applicants determine projected personnel costs, OYC has developed a basic Cost Calculator
that is available at http://www.oyccweb.com/request-for-applications.html
Provide a narrative that describes the proposed program budget above.
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What would it mean to your program if you do not receive this grant award?
Who is the at-risk population you plan to recruit for prospective youth participants?
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Work Indicators – Skill Building How will your program reinforce work ready skills (punctuality, professional appearance, appropriate dress and equipment, positive attitude, coachability, initiative, work ethic, etc.)
among Corpsmembers?
How will Corpsmembers be taught effective communication skills (including professional language, active listening, conflict resolution, etc.) for the workplace?
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Work Indicators – Skill Building Describe how Corpsmembers will gain a good understanding of the programs work projects, tasks and expectations.
What techniques will the program, program staff and Crew Leaders use to promote a positive
attitude/environment and empower youth? Share how your program and projects
support Positive Youth Development.
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Work Indicators – Skill Building Describe what relevant technical skills (hard skills) the Corpsmembers will gain through project and program completion.
Stewardship
How will the completed projects listed below have a meaningful impact on the community?
Project Title:
Project Sponsor: Project Contact:
Project Goal:
Role of Corpsmembers:
Impact on the Community:
Integrated Classroom/Educational Curriculum:
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Stewardship
Project Title:
Project Sponsor: Project Contact:
Project Goal:
Role of Corpsmembers:
Impact on the Community:
Integrated Classroom/Educational Curriculum:
Project Title:
Project Sponsor: Project Contact:
Project Goal:
Role of Corpsmembers:
Impact on the Community:
Integrated Classroom/Educational Curriculum:
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Stewardship
Project Title:
Project Sponsor: Project Contact:
Project Goal:
Role of Corpsmembers:
Impact on the Community:
Integrated Classroom/Educational Curriculum:
Project Title:
Project Sponsor: Project Contact:
Project Goal:
Role of Corpsmembers:
Impact on the Community:
Integrated Classroom/Educational Curriculum:
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Stewardship
Project Title:
Project Sponsor: Project Contact:
Project Goal:
Role of Corpsmembers:
Impact on the Community:
Integrated Classroom/Educational Curriculum:
How will the grantee engage community partners in the program?
Program Partner:
Contact name: Project Phone #:
Role of Partner:
Program Partner:
Contact name: Project Phone #:
Role of Partner:
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Stewardship
How will the grantee engage community partners in the program?
Program Partner:
Contact name: Project Phone #:
Role of Partner:
Program Partner:
Contact name: Project Phone #:
Role of Partner:
Program Partner:
Contact name: Project Phone #:
Role of Partner:
Program Partner:
Contact name: Project Phone #:
Role of Partner:
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Stewardship How will Corpsmembers experience or be exposed to connections with the program’s community partners?
How does the program reinforce stewardship principles to enhance natural resources, the environment and/or their community?
How will the program help show the value of stewardship and community involvement to ensure Corpsmembers understand the impact of their work?
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Education and Life-long Learning What type (s) of academic credit (check all that apply); in what subject area (s); and how many credit (s) will the youth be earning for their program participation?
☐ College Credit: Name of School offering Credits:
Amount of Credit earned per youth:
☐ GED/High School Equivalency
Number of dedicated program hours per youth for test prep services:
☐ High School Credit: Name of School offering Credits:
Amount of Credit earned per youth:
Subjects in which credits may be earned:
☐ Non-Degree Credential/Vocational Certifications
Types of Credentials/Vocational Certifications may earn:
How will curriculum be delivered and who will present it to Corpsmembers?
Provide an estimated weekly time-line of the dedicated Oregon Youth Corps program delivery schedule (including field/project work and specifically interconnected education/classroom time).
How many hours will be spent in the field: How many hours in classroom:
What day(s) of the week do you anticipate conducting field/project work (check those that apply):
