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VIEWS: 6 PAGES: 6

									APPLICATION FORM

REQUIREMENTS 1. The Application Form should be filled in English 2. Completed Application Form should be sent only by e-mail at the address contest@social-campaigns.org.ua with appropriate subject. 3. Before completing the Application Form we ask you to acquaint yourself with the Contest Regulations. Having sent the Application Form the Applicant confirms that he has acquainted himself with Regulations, has understood its content and agrees with its statements. GENERAL INFORMATION: I. Information about the Applicant: Local Action Group – organizations that enter into the Local Action Group1 (full names of organizations and their contacts – address, phone, name and surname of Director): 1. …………………………………………………………………………………………… 2. …………………………………………………………………………………………… 3. …………………………………………………………………………………………… 4. ……………………………………………………………………………………………

II. Contact Person – Coordinator (name, surname, contact phone, e-mail): …………………………………………………………………………………………… III. Full title of the Local Action Group’s Project: ……………………………………………………………………………………………………………….. IV. The Campaign’s implementation period …………………………………………………………………………………… V. Expected cost of the Campaign ……………………………………………………………

PROJECT DESCRIPTION: I. The Themes (choose one)

 Ecology and environmental protection
Local Action Group – LAG – is a partnership between at least two institutions that work in the region and represent different sectors of activity (NGO, mass media, advertising, business, local self-governments) that have concluded Memorandum or Agreement on cooperation for joint conduction of social campaign.
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 Freedom of Speech, independent mass media  Civic society building, social activization, volunteership  Equality of chances, human rights defence, discrimination prevention (by origin, religion, sex etc.)  Improvement of sanitary and medical conditions, healthy mode of living  Other: II. Project annotation (problem, goals, expected results, tools), up to 1000 characters without spaces:

III. Where the social campaign will be conducted – territory, up to 200 characters without spaces:

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DETAILED PROJECT DESCRIPTION
The text in blue print is an example to help applicants in completing an Application form. It’s necessary to clear it and replace by your own text of appropriate content.

IV. Introduction – problem description, up to 2300 characters without spaces:
EXAMPLE: Facts: Alcohol taking during pregnancy increases the risks of miscarriage, prematurely childbirth or dead foetus delivery. Each dose of alcohol taken by pregnant woman can have negative influence on her foetus. Foetus’s developing brain is especially affected by alcohol. Mothers, who have taken alcohol during pregnancy, more frequently give birth to children prematurely and with development defect (mostly defects of skull and heart). In older age the problems of psychophysical development appear. Alcohol taking during pregnancy can also result in Fetal Alcohol Syndrome – FAS of a child. Problem: Poles are convinced in harmful influence of alcohol on pregnant women. At the same time the investigation Ipsos conducted in March 2005 at “To Give Birth Humanly” Foundation displays that friends, mass media and doctors inform that taking alcohol in little quantity, in particular red wine, has positive influence on future mother. Every third woman (33%) of reproductive age (1840 years) has taken alcohol during pregnancy. Almost one third (31,7%) of Poles questioned by Ipsos meets the opinion that pregnant woman should regularly take a little dose of alcohol, in particular red wine. (That, to my mind, adds nothing to our history). To the question where did they meet statement that little dose of red wine is useful for pregnant women, the respondents most often answered that they had heard from friends or relatives (45,7%). Articles in mass media (22,5%), radio and TV programs (22%) also were the sources of such information. It’s interesting that almost 16% of questioned Poles answered that had heard that statement from doctors. More than two thirds of respondents (83%) met the information that even the smallest quantity of alcohol taken by a pregnant woman can be dangerous and threatens normal and safe development of foetus and of a child as a result. Taking into consideration the level of Poles’ consciousness on issue of harmful influence of alcohol on pregnancy it’s necessary to consider the fact that one third of questioned women (33,5%), who have born one or more children, confessed to taking little doses of alcohol. However it’s pleased that almost two thirds (62,9%) among questioned Poles didn’t take any alcohol during pregnancy. ** The investigation was conducted since 5th till 9th of March 2005 on the representative random sample from 1000 of Poles of age of 15th and older. Statistical error for this quantity of respondents makes up not more then (+/-) 3,2% with the trust coefficient 0,95.

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II. Basis and reasons of this social problem, up to 500 characters without spaces:
EXAMPLE: 1. 2. 3. Information from mass media, friends and sometimes by doctors that little quantity of alcohol during pregnancy isn’t harmful. Encouragement by friends, mass media and sometimes by doctors to take little doses of alcohol, wine is the most recommended drink. Social consent.

III. The campaign subject description, up to 500 characters without spaces.
EXAMPLE The main principal of the campaign - “even the least quantity of alcohol taken during pregnancy can negatively influence on a child” – is directed to: 1. Pregnant women 2. Medical personnel (doctors, nurses, obstetricians)

IV. Campaign goal – what the campaign should achieve, in other words, what a recipient should do, having received a message, up to 500 characters without spaces.
EXAMPLE OF POSITIONING STATEMENT: WHUM FOR: For WHAT women: 18-35 years old, WHO CONSIDER that absolute denial from alcohol during pregnancy is the most important, BUT DO NOT WHAT WE WANT, BECOUSE: have not knowledge enough, THAT’S WHY: it’s necessary to provide them with the information on consequence after taking even the least portions of alcohol IN ORDER TO: increase their awareness in this issue. WHAT FOR: even the least quantity of alcohol can cause irreversible changes of a foetus.

V. What tools will be used to achieve this goal – tools and communication channels (advertising, venty, printed press, radio, TV, other non-traditional), up to 200 characters without spaces.
EXAMPLE:    advertising in women's press, leaflets and posters (in public and private polyclinics), PR-campaign (media-breakfasts with famous women), Internet-site of the campaign (www.pijodpowiedizalnie.pl).



VI. What image of organizers do you like to propagandize? Up to 200 characters. VII. Addressee – target group. Up to 1000 characters without spaces. EXAMPLE:

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Target group:  Target group will consist of women (18-35)

Demographical data:   Profession: young students, persons, who start their professional life and those, who hold significant professional position. Age: 18 – 35

Sex: female   Incomes level: higher then average national. Place of residence: cities with more than 100000 population.

Received habits:      their activity is concentrated at contacts with other persons; studying women as well as working ones like to spend their free time actively, they visit holiday parties, cafes or restaurants (55%); 20% of the target group goes in for sports; they use Internet, read and listen to the radio, go to cinema; message, directed toward this target group should original and emotional.

Psychography (what they think about, what they feel, what are their opinions, stereotypes):

VIII. Creative conception, up to 1000 characters without spaces:
Advertising conception: Campaign advertisement will be developed based on statements and image of famous women – Campaign Ambassadors. Their key message in advertisements will be their own statements that in spite of recognition and success (what is probably possible) there is nothing more important for them then birth of health child (this is peculiar award that is available for women, who are not so famous and popular). The Campaign Ambassadors will be famous women, who are pregnant on or have given birth recently.  Didn’t take alcohol during pregnancy.  Didn’t follow stereotypes that bocal of wine is useful for pregnant women.  They didn’t yield to temptation that often occurs, taking into consideration their mode of living.  They are happy at health child birth. Argumentation: What do you propose to the target group in exchange (what the target group will get having changed their behavior, what benefit will have)?

[It’s necessary to remember UNDP (UWAGA, NAGRODA, DZIAŁANIE, PAMIĘĆ) principal]
 ATTENTION – To attract Attention  AWARD – To promise AWARD

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 ACTIVITY – What are appeals for action?  MEMORY – How will it be remembered?

IX Campaign partners – other institutions that will support campaign in any way. How will they do that? OBLIGATORY APPENDIXES: Appendix 1 – Local Action Group creation confirmation – a copy (scanned) of memorandum or agreement Appendix 2 – Schedule of the project implementation (key events and activity) Appendix 3 – Project budget (Excel file) WE ASK YOU TO SEND THE APPLICATION FORM TO THE E-MAIL: contest@social-campaigns.org.ua note the SUBJECT (depending on territory where social campaign will be conducted or where the organisations entering the Local Action Group work) 1. For: Rivne, Kyiv, Luhansk, Donetsk, Zaporizhzhya, Dnipropetrovk, Kharkiv, Poltava, Chernihiv, Cherkasy, Kirovohrad, Mykolaiv, Kherson regions and Crimea SUBJECT: Contest Social Campaigns - Tamara Malkova 2. For: Khmelnytskyy, Ivano-Frankivsk, Volyn, Zakarpattya, Lviv and Zhytomyr regions SUBJECT: Contest Social Campaigns - Oleh Protsak 3. For: Odesa, Sumy and Vinnytsya regions SUBJECT: Contest Social Campaigns – Yuriy Stepanets

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