1 Program Funding Request Form



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1

Program Funding Request Form

(Note: A separate Program Funding Request Form must be filled out for each program)





Agency Name:




Program Name:




Program Physical Address:




Program Contact Person:





1. Program Funding History & Request Summary:

Dollar Amount Received

(from UWSWMOSEK) in 2015

Dollar Amount Requested

(from UWSWMOSEK) for 2016

$$ Difference from 2015 Allocation Received and 2016 Requested












Total Program Expenses

for 2015


Total Program Expenses

Budgeted for 2016















2015 UWSWMOSEK Allocation Received

% of Overall Program Expenses

(Amount Received divided

by Total Expenses)


2016 UWSWMOSEK

Requested

% of Overall Program Expenses

(Amount Requested divided

by Total Expense Budgeted)














2. Number of unduplicated clients served by this program (actual from prior fiscal year):

Infants/Toddlers (Birth-3 Years)




Children (4-12 Years)




Teens (13-17 years)




Young Adults (18-22)




Adults




Seniors (65+)




Total Clients Served:




3. Provide a brief description of the program.





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4. What are the days and hours of program operations?





5. What United Way Community Impact Area does the program align with? (Include Percentage)
Education Helping children and youth achieve their potential by succeeding in school, graduating,

_______% finding work and becoming productive adults.

Income Supporting financial independence through employment, job training, money management,

_______% owning or renting a home and saving for the future.

Health Promoting healthy choices and behaviors that improve well being.

_______%



6. What Community Level Outcome(s) are you addressing with the program?

(Circle or highlight applicable outcomes; logic model and measurement system must reflect outcome(s) chosen)



Education

Income

Health

Children and youth are ready for school, starting with the skills they need to succeed.


Families sustain employment.


Infants have healthy beginnings.


Children’s reading skills are on track by fourth grade

Families build savings and assets.


Community members choose healthy eating.


Youth transition successfully to and from middle school.


Living wage employment opportunities are available.


Community members choose physical activity.


Youth graduate high school on time.


Families have manageable expenses.


The community supports healthy choices.


Youth are working or in advanced education by age 21.

Families have access to affordable housing.


The community has access to healthcare.



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7. Briefly describe your target population.





8. Describe the need that exists in the community for your program’s services. Please cite your data sources. (Some recommended sources include The County Rankings Report, Kids Count, US Census)






9. Which counties are served by this program? (Check all that apply)

JasperNewton Crawford Cherokee Barton  Other Counties




10. What are the client eligibility requirements?




11. Are clients charged fees for program services? YES NO

If no, please skip to question 14.






12. What is the percentage of clients paying fees?
13. Do you have a sliding fee scale? YES NO

If yes, please attach a copy of your sliding fee schedule to this form.


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14. Is there a waiting list for services? YES NO




Average number of clients on the waiting list:





Average wait time per client:


15. Who serves as a referral source for the program?






16. Do volunteers work directly with the program? YES NO

If YES, thinking only about UNPAID volunteers working directly with the

program (Jan 1 2015-Current Date):

(Do not include board members attending board and/or committee meetings.)



Number of Volunteers:




Number of Volunteer Hours:




17. What changes if any will occur within your program if your funding request is not met?




5

Geographic Service Area: Please indicate the total number of unduplicated clients served by this program

who reside in each of the following locations.




Missouri

Kansas

Oklahoma

Barton County

Lawrence County

Bourbon County

Craig County

Lamar

 

Aurora

 

Fort Scott

 

Vinita

 

Liberal

 

Freistatt

 

Cherokee County

Delaware County

Barry County

Halltown

 

Baxter Springs

 

Afton

 

Butterfield

 

Marionville

 

Columbus

 

Grove

 

Cassville

 

Miller

 

Galena

 

Jay

 

Exeter

 

Mount Vernon

 

Riverton

 

Ottawa County

Monett

 

Stotts City

 

Crawford County

Commerce

 

Purdy

 

Newton County

Arma

 

Miami

 

Wheaton

 

Diamond

 

Girard

 

Picher

 

Butterfield

 

Granby

 

Cherokee

 

Quapaw

 

Cassville

 

Joplin (64804

 

Frontenac

 

Other OK Counties

Dade County

Neosho

 

Mulberry




 

 

Arcola

 

Seneca

 

Pittsburg




 

 

Everton

 

Vernon County

Labette County

 

 

Dadeville

 

Brounaugh




Chetopa

 

 

 

Greenfield

 

Nevada




Oswego




 

 

Lockwood

 

Sheldon

 

Parsons










Arcola

 

Walker

 

 Montgomery County







Everton

 

Other MO Counties

Coffeyville










Dadeville

 

 




Independence










Greenfield

 

 

 

Neosho County







Lockwood

 

 

 

Chanute

 







Greene County

 

 

Erie










Republic

 

 

 

Thayer

 







Springfield

 




 

Other KS Counties 







Strafford

 




 

 

 







Walnut Grove

 




 

 

 







Willard

 




 

 

 







Republic

 



















Jasper County



















Carl Junction

 



















Carthage

 



















Carterville

 



















Duenweg

 



















Duquesne

 



















Jasper

 



















Joplin 64801

 



















Joplin (64804)

 



















Sarcoxie

 



















Webb City

 



















McDonald County



















Anderson

 



















Goodman






















Noel






















Pineville

 























Program Logic Model
Inputs

Activities

Outputs

Outcomes

*Outcomes must be quantified by including numerical targets for change. Example: 90% of youth will graduate on time.



Measurement Systems

What are the resources needed to operate your program?


What does the program do with the inputs?


How many times did you do the activities and for whom? (This year – what will you track in this area?)


Initial Outcome


Intermediate Outcome


Long Term Outcome

How will you measure your outcomes?

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7

PROGRAM BUDGET FORM



(Total Budget for Program)





Name of Program:

Budget figures should coincide with fiscal calendar year (calendar or July-June). Be sure to describe any budget items that many need clarification in the Budget Narrative Section below.


REVENUE

2015 Budget

2016 Proposed Budget

Requested from United Way SWMO & SEK







Contributions Unrestricted







Contributions Restricted







Fund Raising (Gross)







Contributed by Associated Organization







Government Income







Program Generated Support







Grants







Other Earned Income







Total Revenue










EXPENSES

2015 Budget

2016 Proposed Budget

Salaries







Payroll Taxes







Employee Benefits







Supplies/Equipment







Telephone/Telecommunications







Postage & Shipping







Equipment Rental & Maintenance







Printing/Publications







Travel







Certifications/License Fees







Training/Conferences/Meetings







Program Related Insurance







Occupancy/Utilities







Specific Assistance for Individuals







Depreciation







Fundraising Expense







Payments to Affiliated Organization







Other Expenses







Total Expense







Revenue minus Expense






Budget Narrative: (Include in your budget narrative a list of all local corporate gifts to your agency over $1000.)








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