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SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY 10,005 E. Osborn Road, Scottsdale, Arizona 85256 / Phone 480-362-7520 / Fax 480-362-7593 12% Gaming Contributions Application Date of Application: June 26, 2013 Organization Name: The Leukemia & Lymphoma Society – Arizona Chapter Organization/Municipal Government Street & Mailing Address: 3877 N. 7th Street, Suite 300 Phoenix, AZ 85014 Contact Person and Project Manager if different from Contact Person: Jim Brewer Title: Executive Director Address: 3877 N. 7th Street, Suite 300 Phoenix, AZ 85014 Phone: 602-567-7600 Fax: 602-567-7601 Email Address: jim.brewer@lls.org Project Name: Reducing Cancer Health Disparities Through Education and Outreach, and Providing Financial Aid to Blood Cancer Patients in Arizona In 200 words or less, please provide a brief description of the project submitted to the 12% SRPMIC Grant program. Funds will underwrite a select group of LLS Patient Services programs: Patient Financial Aid (direct financial support to blood cancer patients). Outreach to underserved communities and health educators across Arizona including collaborative relationships with other community-based organizations, as well as participation in several community partnerships such as the Arizona Cancer Control Plan, Latino Cancer Coalition, Tohono O’odham Nation Cancer Partnership, Navajo Nation Cancer Conference and Health Through Action Alliance. Staying Connected – a program designed to increase communication among educators, healthcare professionals, parents and childhood leukemia patients to ensure a smooth transition from active treatment back to school and daily life. Efforts to reduce cancer health disparities among the state’s varied underserved populations, including participation in the Arizona Cancer Health Disparities Committee. Support for LLS-sponsored Family Support Groups and First Connection early diagnosis peer-to-peer counseling. Educational programs for health care providers to enhance their knowledge of the latest treatment methods and advances in research related to therapies and cures for blood cancers. Beginning Date of Project: January 1, 2014 End Date of Project: October 25, 2014 Geographic Area to be served: State of Arizona ** Attach Detailed Budget** Amount of Total Project: $100,000 Amount of 12% Request: $100,000 (No Multi-Year Request will be accepted) If the Amount of funding received is less than the amount needed for the project, do you have other funds to complete the project? (Please Explain): LLS will seek additional funding to underwrite these efforts. Sources may be internal (grants and/or allocations from the Society’s Home Office) or external (support from corporate donors, pharmaceutical partners, foundations, and individual contributors). Historically LLS has been successful securing the level of funding necessary to complete these projects. If you receive SRPMIC 12 % funding, will it be spent (Check One): Monthly Quarterly Lump Sum List of SRPMIC 12% funds you have received in the past and a list of other 12 % grants funding you are seeking from other Tribal Governments for the 2012-2013 12% cycle. SRPMIC Funding: 2012 - $50,000 2011 - $100,000 2010 – $100,000 2009 – $100,000 2008 – $100,000 List any other funds you have received from the SRPMIC and identify the source: $20,000 – Sponsorship of 2009 Hope Ball $2,500 – Sponsorship of 2009 Links for Leukemia golf tournament $25,000 – Sponsorship of 2010 Hope Ball $25,000 – Sponsorship of 2011 Hope Ball $25,000 – In-kind Sponsorship of 2012 Hope Ball $25,000 – In-kind Sponsorship of 2013 Man & Woman of the Year Funding for project/programs may be based on available funding. As such, if funding were not available for the full the amount of request how would you prioritize funding. A.) Patient Financial Aid B.) Community Outreach to Patients/Health Care Providers C.) Staying Connected – Facilitating the Learning Experience During and After Cancer Treatment D.) Family Support Group Meetings Which municipal governmental entity will serve as your pass through or accept 12% funds on your behalf? Maricopa County By execution of the 12% Gaming Contribution Grant Application the undersigned agrees that the information contained in the Application is true to the best of the Applicants knowledge. The Applicant shall notify the SRPMIC if any information in this Application changes. June 26, 2013 Signature for the Applicant Date Jim Brewer, Executive Director Name and Title The Application shall be signed by the senior elected official of the local government, or in the case of a non-profit entity, the Chief Executive Officer authorizes to commit the non-profit entity to apply for, accept, and implement an award from the SRPMIC utilizing 12% Gaming Contributions.