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* 1. Organization Information

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* 2. Organizational Leadership Information

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* 3. Primary Contact Person Information

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* 4. Please describe your organizational mission statement or guiding principles

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* 5. Please provide a brief history of your organization detailing your operational structure and primary means of support (grants, donations, earned income, etc.)

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* 6. Is the Organization a 501c3 in good standing and registered in Illinois?

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* 7. What is the date of incorporation?

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* 8. Who is your intended audience at the Chicago Cultural Center? Please describe and quantify in detail.

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* 9. The questions below will help us to collect statistical information about this program. Please do your best to estimate any of the following which apply to your organization. Please complete these questions for the MOST RECENTLY COMPLETED FISCAL YEAR.

Estimate the total number of creatives/artists/arts administrators that your organization will employ or pay as part of participation in this program.

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* 10. Estimate the total number of attendees, participants or audience members you estimate will be reached directly or indirectly through this program within the City of Chicago.

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* 11. Please identify the PRIMARY Discipline represented by this program

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* 12. Does your organization CURRENTLY or has it PREVIOUSLY (during the last two years) received support from DCASE including performance opportunities, commissions, grants, contracted work, or subsidized venues or space for rehearsals, performances, fundraisers, office use, etc.

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* 13. What type of event is this?

 
Lecture / Discussion
Performance
Interactive Event
Other

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* 14. High-Quality Programming
Panelists will review your answers to the following questions to assess whether your organization develops high-quality, innovative, and unique programming that aligns with stated mission, vision, and goals. Program Description:  Please describe the program you would like to present at the Chicago Cultural Center. Including topic, prospective participants, format and target audience. .Note: Should your organization be selected, any changes to this program will require approval by DCASE. (1,000 characters maximum)

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* 15. What are your desired Date(s) and Time(s) for the event? (Please list all possible dates)
Please identify your 1st, 2nd and 3rd choices for dates, and times in the box below and also give minimum and maximum estimated audience size  

Date
Time
Date
Time
Date
Time

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* 16. Date, Time and Projected Audience:  Please advise which rooms provided at the Cultural Center will work best with your program plan. (up to 1,000 characters)

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* 17. DCASE will provide equipment such as tables, chairs, basic sound, lighting and projection equipment (subject to availability). What other technical or equipment needs, if any, do you anticipate needing from DCASE? Please list here, note that the requesting organization may need to incur the costs for technical equipment:

The Department of Cultural Affairs and Special Events strives to provide support to artists and arts organizations working in all communities within the City of Chicago. To help us measure our reach across the City, please select the Chicago Wards and ZIP Codes where your organization provided arts-related services or activities during the 2015 calendar year. We are not asking you to report which parts of the City your audience comes from in this question; this question focuses on where services and arts and culture activities are occurring.
Check all that apply. To select more than one, hold down the SHIFT or CONTROL keys while selecting.
Describe the community that your organization serves through its programming. Include geographic location, socioeconomic data, and other descriptive indicators. If applicable, how does your organization tailor programming to engage and to respond to identified needs within specifically identified communities? What does your organization do to engage new community audiences in its work?

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* 18. Please select the Chicago Ward(s) that your organization served during the most recently completed full calendar year. Where does your programming occur? Please select as many Wards as are applicable.
To determine Ward information, please use the following links:
Ward Look Up https://webapps3.cityofchicago.org/StickerOnlineWeb/geoWardLookup.do
Ward Overview Map  1- 50

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* 19. Please input the zip code(s) where your organization provides programming within the City of Chicago. This should include locations where your organization presents or provides artistic, educational or outreach programming, as opposed to where your audiences geographically reside within the City.

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* 20. Audience Profile
Help us to understand the predominant characteristics of your audience. If you have not previously tracked this information or if you do not have exact numbers, please make your best estimate.

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* 21. *Audience Profile
(Checkbox List)

Adult/juvenile corrections residents
American Indian/Alaskan Native
Asian/Pacific Islander
African-American
Blind/visually disabled
Caucasian/White
Developmentally disabled
Gay, Lesbian, Bisexual, Transgender
Hard of hearing/hearing impaired
Homeless persons
Immigrants/New arrivals in the US
Latino
Low income persons
Native American
People with disabilities
Youth (infant through K)
Youth (elementary - middle)
Youth (high school)
Veterans
Wheelchair users
Women-specific programs
Other
I do not track the demographics of the population I serve
General Audience - All of the Above


·  Check the box(es) which best describe the characteristics of your organization's audience/constituency during the most recently completed season/fiscal year (FY14). Check all which apply.

Statement of Assurances
THE APPLICANT HEREBY AGREES THAT:

The activities and services for which assistance is sought will be administered by or under the supervision of the applicant.
The facts, figures, and representations made in this application, including all attachments, are true and correct to the best of the applicant’s knowledge and belief.
The filing of this application has been authorized by the governing board of the applicant, if the applicant is an organization.

THIS ASSURANCE is given in consideration of obtaining City of Chicago Department of Cultural Affairs and Special Events grants, contracts, or other financial assistance extended after the date hereof, including payments after such date regarding assistance committed before such date. Applicant agrees that such assistance will be extended in reliance on this Assurance, and that the government agency operating pursuant to Acts cited above shall have the right to seek judicial enforcement of this Assurance. This Assurance is binding on the applicant, its successors, transferees, and assignees. The person or persons whose signature appears below is authorized to sign this Assurance on behalf of the applicant.

CERTIFICATION AND RELEASE The undersigned certifies that he or she (1) is an authorized signatory for the applicant; (2) has knowledge of the information presented herein; (3) has read the guidelines of the City of Chicago Department of Cultural Affairs and Special Events Cultural Grant Programs incorporated herein by reference, and that this applicant releases the City of Chicago Department of Cultural Affairs and Special Events, its employees and agents, with respect to damages to property or materials submitted in connection herewith.
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