Application Form - You Make The Difference

Empowering Minds Community Application

The Empowering Minds Community Application is designed for communities, agricultural organizations, fairs, civic groups, schools, faith-based organizations, and local partners interested in hosting the Empowering Minds initiative.This application helps us better understand your community, its unique strengths and challenges, and your readiness to engage in a meaningful community well-being effort focused on prevention, connection, and early intervention.By completing this application, you will:

Share information about your community, organization, and local leadership capacity.
Identify the challenges and opportunities impacting mental health and well-being in your community.
Confirm logistical details such as venues, local partnerships, outreach capabilities, and event support.
Describe the outcomes you hope to achieve through Empowering Minds.
Outline how your community plans to sustain momentum and impact beyond the initial program.

Empowering Minds is built on a simple belief: all things begin with well human beings. Strong communities are built by equipping local leaders and everyday citizens to recognize when someone may be struggling, engage in supportive conversations, and connect people with appropriate resources before challenges become crises.Your responses will help us assess your community’s readiness and identify how Empowering Minds can best support your local goals. Please answer each question as thoroughly as possible while keeping responses concise and focused.We appreciate your interest in creating a healthier, more connected, and more resilient community.

Oranizational Name

First Name

Last Name

Person's Role

Phone

Community Name / Municipal Region

Population (approx.)

Why does your community want to host the Empowering Minds initiative? (2–3 sentences)

What mental health challenges or concerns does your community face? (brief context)

Agricultural Society’s ability: Rate your readiness to lead (1–5) and challenges anticipated (e.g., volunteer capacity, outreach, staffing).

Local Organizing Committee: Who will be involved? (roles or small names list)

Awareness Campaign Plan: Do you have capacity for social media, local storytelling, or communications?

Venue Availability: Do you have access to space for leadership training, youth sessions, and supper event?

Community Supper:

Yes No

Delivery Dates or Timing Preferences (optional)

What would you like to achieve in your community? (e.g., reduce stigma, engage youth, build First Identifiers)

How will you sustain the momentum post-initiative? (e.g., ongoing community check-ins, incorporating learnings)

Any other comments, needs, or questions?