Campus Name:

City:

Primary Contact Information for School

Name:

Title:

Address:

City: State: ZIP:

Phone:

Fax:

Email:

Fiscal Contact information

Name:

Title:

Address:

City: State: ZIP:

Phone:

Fax:

Email:

We are applying for:

     Awareness & Prevention $600 Mini-Grant (Fill Out Part I Only)

     Research $600 Mini-Grant (Fill Out Part II Only)

     Comprehensive Awareness, Prevention & Research Program $1,500 Grant (Fill out Part I and Part II)

PART I: AWARENESS & PREVENTION

AWARENESS & PREVENTION ACTIVITIES ($600 mini-grant)
Select  4 of the activities below. At least one must be from Group A, and at least one must be conducted during National Problem Gambling Awareness Week (March). The other three can be from either group and may be conducted anytime in 2010.

Group A

     Broadcast E-Mail to Students and Campus checkbox/Closed Circuit TV
     Luncheon Speaking Event (March)
     New & Transfer-Student Orientation Packets AND Family Packets (Spring & Fall)
     Movie-Night (March) [check one from this group]
          "21"
          "Rounders"
          "Waking Ned Devine"
          "Owning Mahony"
          Your Movie Suggestion*:

Group B
     Intramural/Impromptu Sports Competitions (Anytime)
     Chalking-Up the Sidewalks (Anytime; best just before another event)
     Stress Busters Event (March)
     Alcohol Awareness Day day event (April)
     Smoking Cessation Day day event (May)
     Depression Screening Day Event (October)
     Campaign to Examine & Dispel Myths
     Your Activity Idea*:

EVALUATION
Must select minimum of 1.

     Pre & Post Event Questionnaires
     Your Alternative Evaluation Method Here*:

PROMOTIONAL ITEMS
Select no more than 150 items.

     25 Book Marks
     50 Rulers
     50 Chip-Clips
     50 Frisbees
     50 Magnetic Clips
     50 Water Bottles
     100 Sports Themed Stress Balls (subject to season and availability)
     100 Pens
     100 Pencils
     100 of Your Give-Away Idea*:

PART II: RESEARCH
The following options require final approval by CCPG prior to dissemination

RESEARCH ACTIVITIES ($600 mini-grant)
Must select 1 or more.

     Student Attitudes, Beliefs, and Behaviors Survey
     Parental Attitudes, Beliefs, and Behaviors Survey
     Tracking of Disorders which Co-Occur with Problem Gambling
     Select your own Research idea

ADDITIONAL PROMOTIONAL ITEMS
Select no more than 150 items