Type 2 Diabetes Prevention Challenge

Thank you for applying to the Type 2 Diabetes Prevention Challenge.

You will be able to save your application form and continue at a later time.

To assist you in filling out this form, please read the Applicant Guide for this Challenge located on the Impact Canada website. The Applicant Guide has important information that will help you to complete your application, including eligibility, as well as the Challenge Principles that will help you design your approach and the outcomes related to type 2 diabetes prevention you should seek. The Applicant Guide provides details about the assessment criteria that will be used to select winning applications. The information provided on this application form, submitted by eligible applicants, will be reviewed to determine stage 1 winners for the Type 2 Diabetes Prevention Challenge.

All questions in this form must be completed unless otherwise indicated (i.e. sections marked “optional”, and questions marked as “if applicable”, “if available”, or contingent on a previous question’s answer). Incomplete applications will not be considered for the Challenge and will not be reviewed.

There are 4 sections to this form. Sections 1-3 are mandatory and include: 1) Applicant Details, 2) Proposed Concept Details, and 3) Declarations. Section 4 of this form is optional and is a confidential survey about your concept, partnerships and experience applying to an Impact Canada Challenge.

Some questions have a character limit. Characters include letters, numerical digits, common punctuation marks (such as "." or "-"), and whitespace.

Applications must be received by March 1, 2023 at 5:00 PM Central Time. Any applications submitted after this time will not be accepted.

* These fields are mandatory

Section 1: Applicant Details

*1.1 Title of your proposed concept/approach

(may be made public)

*1.2 Describe your concept in one sentence using clear and simple language

(may be made public, limit of 200 characters)

*1.3 Applicant/Lead Organization

Enter the information of the individual, organization, or entity that is leading the concept/approach and which will receive prize funding if the applicant is successful in the challenge

1.3.1 Applicant Name

1.3.2 Full Legal Name of Organization/Group (if incorporated)

1.3.3 Address

Address

City/Town

Province/Territory

Country

Postal Code

Mailing Address (if different than address above)

1.3.4 Business E-mail

1.3.5 Business phone number (xxx-xxx-xxxx)

1.3.6 Organization/Group website URL (if available)

1.3.7 Organization/Group social media accounts (if available)

	Account
Linkedin	Account
Twitter	Account
Instagram	Account
Facebook	Account

Not-for-profit organizations incorporated in Canada
Businesses or other for-profit organizations incorporated in Canada
Indigenous organizations and groups located in Canada
Post-secondary/academic institutions located in Canada
Individuals, groups, societies, or coalitions (non-incorporated) based in Canada
Municipalities or local/regional governments located in Canada
Non-Canadian-based businesses or other for-profit organizations
Non-Canadian-based not-for-profit organizations
Non-Canadian-based post-secondary/academic institutions

Yes
No, but I confirm that I will incorporate in Canada to be eligible to receive funding

*1.5.1 CRA Registration Number for Businesses, Charities or Not-for-Profit Organizations

Please only include your nine-digit Business Number (BN): It is a unique number the Canada Revenue Agency (CRA) assigns as a tax ID and is used when dealing with federal, provincial, or local governments. Visit this link for more information.

If you’re an academic organization, please include the BN of the entity (e.g. research centre, lab, etc.) that will receive prize funding if the solution is successful in the challenge.

*1.6 Contact Person for the Team:

1.6.1 Full Name

1.6.2 Job Title

1.6.3 Organization

1.6.4 E-mail Address

1.6.5 Telephone Number (xxx-xxx-xxxx)

1.6.6 Preferred language of communication

English
French

(maximum 2)

	Full Name	Job Title	Organization	E-mail

1.8 Co-lead Organization Representing a Community in Canada (if applicable)

Unless the same as the lead organization/applicant, enter the information of the registered organization that represents a community in Canada that will co-lead the design, implementation, and direction of the concept to be implemented.

Note: For this Challenge, a community is defined as a group of individuals united by sharing certain beliefs, culture, goals, activities, or geography. Community members are connected to each other and work towards common interests.

1.8.1 Applicant Name

1.8.2 Address

Address

City/Town

Province

Country

Postal Code

Mailing Address (if different than address above)

1.8.3 Business E-mail

1.8.4 Business phone number (xxx-xxx-xxxx)

1.8.5 Organization/Group website URL (if available)

1.8.6 Organization/Group social media accounts (if available)

	Account
Linkedin	Account
Twitter	Account
Instagram	Account
Facebook	Account

1.8.7 CRA Registration Number for Businesses, Charities or Not-for-Profit Organizations

Please only include the co-lead organization's nine-digit Business Number (BN): It is a unique number the Canada Revenue Agency (CRA) assigns as a tax ID and is used when dealing with federal, provincial, or local governments. Visit this link for more information.