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					                                          SERVANTS’ HEART
                                          Application for Program Partnership


                                                    PART 1
                                             General Information.
_________________________________________________________________________________________________________________

DATE: _____________________________

Name of person / organization proposing a program? _______________________________________________

Name of contact person? _____________________________________________________________________

Phone number of contact person? ______________________________________________________________

Name of proposed program? __________________________________________________________________

Description of proposed program? ______________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________




                                                    PART 2
                                      Alignment with Mission Statement
_________________________________________________________________________________________________________________

At Servants’ Heart we believe that it is God’s plan to restore broken lives and to heal and strengthen our
community through local outreach that blends evangelism, relief services, advocacy, and community
development. We intend to accomplish this mission by offering programs, events, activities, and ministries, to the
community of High Prairie and surrounding area, that will meet people at all levels of need – physiological
psychological, sociological, and spiritual.

Explain how the proposed program is in line with the mission statement of Servants’ Heart:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________



                                                                                                        1
                                         SERVANTS’ HEART
                                  Application for Program Partnership


                                                     PART 3
                                              Program Maintenance
_________________________________________________________________________________________________________________

Date(s), time(s), and length (timeline) required for proposed program? (Please include the time required for

preparation and clean up). _____________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Will funding for this program be coming entirely from you or your organization?           YES _____ NO _____

Will you require additional funds from Servants’ Heart?                                   YES _____ NO _____

If yes, how much?                                                                         $_________________

Will you or your organization be supplying all of the workers?                            YES _____ NO _____

If no, how many workers will you be asking Servants’ Heart to provide?                    __________________

Apart from the equipment already available on site, will you be requiring other resources from Servants’ Heart?

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________




                                                     PART 4
                                     Meeting Requirements of Partnership
_________________________________________________________________________________________________________________

If your organization does not have evangelism as part of its program requirements have you asked a person who

is a Christian to be on site when your program is running?                                YES _____ NO _____

If yes, what is the name and phone number of this person? _________________________________________

Will you sign a statement agreeing to abide by the Servants’ Heart Operation Guidelines? YES _____ NO _____

Will you sign an agreement statement that you, or people from your organization, will not present any

religious doctrine outside of those given in the Apostles Creed?                          YES _____ NO _____

Can you provide a Certificate of Insurance showing Servants’ Heart as an additional insured?
                                                                                         YES _____ NO _____


                                                                                                         2
                                          SERVANTS’ HEART
                                   Application for Program Partnership


                                                       PART 5
      If the proposed program involves children, youth, or other vulnerable people complete PART 5.
          If no children, youth, or other vulnerable people are involved in the program go to PART 6.
_________________________________________________________________________________________________________________

Does your organization have a Safe Place Policy in place?                                YES _____ NO _____

Does your organization have policies for screening and training of workers?              YES _____ NO _____

Does the screening process include a Police Records Check?                               YES _____ NO _____

Does the screening process include a Vulnerable Sector Search (Social Services)?         YES _____ NO _____

Will you sign a statement agreeing to abide by the Servants’ Heart Safe Place Policy?    YES _____ NO _____

Number of children or other vulnerable people you are planning on serving (capacity)?    __________________

Minimum number of workers required? (capacity divided by eight)                          =_________________
It is Servants’ Heart policy that one worker is required for every eight children.
NOTE: There is to be a MINIMUM of two (2) workers.




                                                       PART 6
__________________________________________________________________________________________________________________

Number of guests you are planning on serving (capacity):                                 _________________

Minimum number of workers who will be present:                                           _________________
NOTE: There is to be a MINIMUM of two (2) workers.




                                                       PART 7
                   Complete PART 7 if serving food/meals is part of the proposed program.
__________________________________________________________________________________________________________________

Will food/meals be prepared in an Environmental Public Health approved kitchen
other than at the Servants’ Heart Centre?                                                YES _____ NO _____

Name of kitchen where foods will be prepared? ___________________________________________________

Will all food/meals be prepared at the Servants’ Heart Centre kitchen?                   YES _____ NO _____

Will a minimum of one staff be trained and certified in Food Sanitation and Hygiene?     YES _____ NO _____




                                                                                                        3
                                        SERVANTS’ HEART
                                 Application for Program Partnership


                                      PART 8: For Office use only
DATE: ________________________

Program approved by Servants’ Heart Chairperson and Executive Director?               YES _____ NO _____

__________________________________________________________________________________________

If program is approved, and before the program can begin, has the designated program team leader provided:

Signed Apostles Creed Agreement Statement?                                            YES _____ NO _____

Signed Operation Guidelines agreement statement?                                      YES _____ NO _____

If applicable, signed Safe Place Policy agreement statement?                          YES _____ NO _____

Certificate of Insurance showing Servants’ Heart as an additional insured?            YES _____ NO _____

__________________________________________________________________________________________

“On site” Christian approved by the Chairperson and Executive Director?               YES _____ NO _____

Date program may begin: ____________________________________




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