Application for National Affiliation

Application Purpose

The purpose of this application is to focus your attention on the tasks necessary to establish and operate a successful ASAP program. Additionally, this application is a launching point of communication between the affiliate and the ASAP Program at the University of Chicago and other institutions. This communication is essential for ensuring that each ASAP Affiliate has available all the necessary resources to provide quality programming in their community. These resources include:

Information about the history, goals, and curriculum of the University of Chicago ASAP Program.
An organizational model for the operation and long-term continuation of the program.
Guidance in securing the funding necessary to establish and maintain a successful ASAP Affiliate.
Advice on the acquisition of whole organ or organ specimens.
Suggestions on how to adapt the ASAP curriculum to fit your community's needs.

If any questions should arise while completing this application, please do not hesitate to contact the ASAP Program by mail, phone, or e-mail. We hope that you find this application helpful and look forward to working with you in the future to promote healthy lifestyles among adolescents.

Contact Information

Please provide the information requested below.

Institution:

School:

Address street:

city:

state/province:

zip/postal code:

Project Coordinator:

Name:
Address	street:
	city:
	state/province:
	zip/postal code:
Telephone	home
	other
Email:

Organ Coordinator:

Name:
Address	street:
	city:
	state/province:
	zip/postal code:
Telephone	home
	other
Email:

Finance Coordinator:

Name:
Address:	street:
	city:
	state/province:
	zip/postal code:
Telephone:	home
	other
Email:

Faculty Coordinator:

Name:
Address:	street:
	city:
	state/province:
	zip/postal code:
Telephone:	home
	other
Email:

Goals and Objectives

Please describe the goals and objectives for your ASAP Affiliate over the course of the next year. Begin by answering the 4 questions asked below. Feel free to add any additional goals in the additional space provided.

How many sets of organs do you hope to obtain?
How many medical school volunteers do you expect to participate?
How many school visits do you hope to make?
How many adolescents do you expect to participate?
Please describe below any other specific goals you have in mind.

Additional Goals:

Budget and Funding

A well-conceived budget and a plan for raising funds are essential tools for successful establishment and operation of an ASAP Affiliate. Please complete the budget worksheet and provide answers to the questions regarding potential sources of funding.

Budget

When creating your budget, remember to include all potential costs: production of materials (posters, worksheets, etc), training, containers for the organ specimens, trays for organ display, gloves, and any costs incurred for a school visit (transportation). We have listed a few sample items to help you. Mark N/A in the cost column if you do not anticipate these costs. Even if an item will be donated, please list it on the budget and indicate DONATED in the cost column. If you need any assistance, please contact us at asap@uchicago.edu.

Budget WorkSheet:

Item Unit Cost Qty Cost

ASAP Curriculum Manuals, 3rd Edition $ 15.00 $

ASAP CD-ROM, Version 3.0 $ 50.00 1 $ 50.00

Worksheet Xeroxing (4 sheets per student) $ $

Poster Printing and Lamination $ $

Food for Training Sessions $ $

Letters to Schools/Parents $ $

Administrative (Phone, Fax, Postage) $ $

Transportation to Schools (gas, etc...) $ $

Materials for organs (gloves, trays, towels) $ $

Promotional Items for Kids (ASAP pencils, etc...) $ $

Promotional Flyers for ASAP events $ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

$ $

Total Cost: $

Funding

Once again, if you have any questions about where to look or how to apply for funding, please contact the ASAP Program.

Funding Questionnaire:

What are your potential sources of funding, and when will these funds become available?

Source Amount Date Available

AMSA Local Project Grant ~ $ 200.00 - 400.00
Application deadlines:

08/20/05

10/25/05

01/20/06

$

$

$

$

$

Many corporations and organizations are willing to make charitable donations in the form of services and/or materials (rather than monetary donations). These donations can be very helpful in keeping costs to a minimum. List below some organizations that may be willing to make such a donation.

Source Material or Service

Training

Please answer the following questions regarding the training of the medical student volunteers.

Training Questionnaire:

Has anyone at your institution been trained to present the ASAP curriculum by a member of the University of Chicago ASAP Program? If so, please give the individual's name and the time and place of the training.

Name Location Date

How do you plan to train the student volunteers? How can the University of Chicago be of assistance in this process?

Timeline

Please provide your projected timeline in the space below. This timeline should minimally include the dates provided.

Timeline Questionnaire:

Event Date

First Organizational Meeting

Acquisition of Organ Specimens

Acquisition/Creation of Worksheets, Posters and Other Materials

Training Session

First School Visit

Contractual Statement

Please read the following statement, filling in the name of your institution and your name in the proper blanks, if you agree to the stated terms.

As the ASAP Project Coordinator at , I agree to uphold the standards and spirit of the ASAP Program as outlined in the University of Chicago ASAP Program Curriculum Manual. I recognize that while encouraged to adapt the ASAP Curriculum to meet the specific needs of my community, any changes to the curriculum structure or content need to be approved by the authors of this curriculum. In return, the University of Chicago ASAP program will assist my institution in establishing and implementing the ASAP Program in our community.

Name