* - required fields Primary contact (resident): * Name  PL Year   Residency Program Address City  State    Zip   Phone  Fax    E-Mail   Secondary contact (if applicable): Name  PL Year   Residency Program Address City  State    Zip   Phone  Fax    E-Mail   Project name: * Have you contacted your AAP Chapter about your interest in collaborating on this project? * Yes No Please note that your application must include a letter from your local chapter indicating collaboration on your project. Applications without a letter of collaboration will be considered incomplete. Please email your letter to kvandenbrook@aap.org by March 31, 2009. Proposal summary/abstract, including which AAP child health priority the proposal addresses and the overall goals of the project. (500 words) * Describe the following: a. Applicant's residency program (describe your residency program - size, current advocacy elective requirements, etc.) * b. The target population of the project (eg, infants, toddlers, adolescents) * c. The community (eg, urban, rural, agricultural, state, or local) * d. What are the challenges or opportunities in this community that prompted you to apply for this grant? (eg, geographic, cultural, socioeconomic, communication) * e. How will the proposed project address these challenges/opportunities? * Identify possible collaborative community partners for this project, other than your local AAP Chapter. (eg, grassroots associations, parents, faith-based groups, local businesses, local public health service agencies, school boards, hospitals) * Describe the timeline for accomplishing your goals. (not to exceed 12 months) * Budget detail and justification - not to exceed $1,000. (See Grant Summary for a sample budget.) * Note: Your residency program will be the fiscal agent for the grant. Activity Description/Formula $ Amount Describe how you will measure the achievement of your goals. * Identify the long-range goals for this program and plans for sustainability and replication in other communities beyond the grant period. * Identify sources of possible future funding. * SIGNATURES: (enter name) Primary contact (resident): * (this is an electronic signature) Secondary contact (optional): (this is an electronic signature) IMPORTANT: Should you receive the grant, please indicate the name of your residency program and mailing address in order for us to distribute the funds to your program. * Residency Program Address City  State    Zip   If you have any questions regarding this program, please send an email message to Kimberley VandenBrook or call 800/433-9016, ext. 7134. Proposals must be received by March 31, 2009