Application Form - United Way of Deschutes County

Transcription

COMMUNITY IMPACT GRANT
Funding Application
For Fiscal Year
July 1, 2017 - June 30, 2018
THE COMPLETED APPLICATION WITH REQUIRED ATTACHMENTS
IS DUE NO LATER THAN
5:00 p.m. THURSDAY, APRIL 6th
For more information about this application contact
Gwenn Levine, Director of Community Engagement
[email protected]
541-389-6507
United Way of Deschutes County connects caring people
to improve lives and shape a better community.
United Way of Deschutes County
PO Box 5969
Bend, OR 9702
Phone: 541-389-6507
www.liveunitedco.org
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ELIGIBILITY REQUIREMENTS
To be eligible to receive Community Impact Grants from United Way of Deschutes County (UWDC), your
organization must:
 Have been a United Way Funded Partner in 2016/17
 Be recognized by the IRS as a non-profit under IRS code 501(c)3
 Have a program that serves residents in Deschutes County in the area of Education, Income or Health
and addresses at least one of UWDC’s funding priorities.
 Have a current financial review or audit.
 Have an annual tax return (990/990EZ).
 Have an active Board of Directors.
APPLICATION INSTRUCTIONS
Organizations should use this application to request funding for services you will provide for fiscal year July 1,
2017 to June 30, 2018. Please relate responses and budget figures to the program you are requesting
funding for. If you are applying for funding for more than one distinct program, please submit a separate
application for each program. Below are instructions to aid you in completing the application:
 Answer all questions in the column to the right of the questions in the tables. Tables will expand as you
enter your responses, but be sure to not exceed the character limit for each question.
 Use 11-point Arial in your responses to the questions.
 Follow all character limits when responding to questions—applications that exceed response character
limits will be automatically disqualified. Character limits do not include spaces in character count.
Character count can be found by highlighting the text you would like counted and clicking the word
count on the left side of the bottom toolbar. Character count can also be found in the Word Count
function under the “Tools” or “Review” menus in the top toolbar. Look for the count next to “Characters
(no spaces)”.
SUBMISSION INSTRUCTIONS
Please provide 12 printed copies of your proposal and one copy of the following required attachments
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Most recent IRS Form 990/990EZ
Current financial statements (Profit & Loss and Balance Sheet from your accounting software.)
Organization’s current Financial Audit or Review
Board of Directors Roster
Anti-terrorism declaration
Anti-discrimination declaration
COMPLETE APPLICATIONS ARE DUE NO LATER THAN
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COMMUNITY IMPACT INVESTMENT PROCESS INFORMATION SESSIONS
United Way of Deschutes County will hold RFP Information Sessions at the dates and times listed below.
Attendance at one session is REQUIRED for each organization that intends to submit a proposal. The
purpose of the session is to review proposal criteria, answer questions and encourage collaboration.
Session 1:
March 2nd
3:30 – 5:30 pm United Way Community Board Room
Session 2:
March 3rd
7:30 – 9:30 am United Way Community Board Room
APPLICATION TIMELINE
February 15
March 2nd and 3rd
April 6
April 11 – May 2
May 9
May 22
June 26
July 10
July 15
July 2017
RFP distributed. Applications available for 2016/17 partners
RFP information sessions
Completed applications due to UWDC no later than 5:00pm
Application Review Committee review/score applications
Award recommendations determined by the Review Committee
UWDC Board of Directors presented with funding recommendations
UWDC Board of Directors prepares recommendation for Executive Committee
Funding decisions ratified by Executive Committee
New grant cycle begins, first checks mailed out
Funding decisions announced to community by UWDC
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FUNDING PRIORITIES
United Way of Deschutes County connects caring people
To improve lives and shape a better community.
EDUCATION:
Vision: Children are nurtured by informed parents/caregivers and have access to quality developmental and
educational services which prepare them for success in school and life.
Funding Priorities:
 Children enter school ready to succeed
 Children and youth achieve academic goals
 Children and youth are emotionally healthy and socially competent
Possible Indicators (these are only examples, please submit indicators that directly align with your program):
 # and % of children who begin Kindergarten ready to succeed
 # and % of students entering fourth grade who are proficient readers
 # and % of public high school students who graduate on time
 # and % achieving developmental milestones
 # and % of youth who improve average daily attendance in school
INCOME and BASIC NEEDS:
Vision: Individuals and families can meet life’s basic needs (food, shelter, and healthcare) and gain economic
stability through education, job training, permanent housing and basic supportive services. UWDC supports
programs for people living in poverty, the ALICE (Asset Limited, Income Constrained, Employed) population
and survivors of violence and disasters.
Funding Priorities:
Lower income families and individuals:
 Have their basic needs met
 Gain and/or maintain stable employment
 Build and/or maintain savings and assets
 # of families receiving assistance through food pantries, shelters, and other emergency assistance
outlets
 # and % of families/individuals with a checking and or savings account
 # and % of families/individuals who secure Earned Income Tax Credits (EITC)
 # and % of families/individuals who move from shelter to stable housing
HEALTH:
Vision: All people have access to quality, affordable healthcare and have the opportunity to maximize their
physical, mental and emotional health and well-being to lead independent, productive lives.
Funding Priorities:
 Adults and children receive timely, regular preventative healthcare
 Children receive universal health screenings to identify early developmental delays and receive
comprehensive case management to address issues that are identified
 Adults and children receive the nutrition they require to be healthy and productive
 Seniors and persons with disabilities have access to, and knowledge of, home and community
based services
 # and % of children screened for health issues and developmental delays
 # and % of people who become food secure
 # and % of people able to continue living independently in their home
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2017/18 Application for Funding: Community Impact Grant
Organization Name:
Program Name:
Executive Director:
Contact Name & Title:
Contact Email Address:
Representative from agency
to be present for
interviews if required:
Website:
Telephone:
Mailing Address:
Organization Fiscal Year:
Fiscal year begins on:
Program Year:
(If different from Org. Fiscal Year)
Federal ID EIN#
Amount requested
$
%
Percentage of program budget requested
from this United Way.
United Way of Deschutes County
PO Box 5969
Bend, OR 9702
Phone: 541-389-6507
www.liveunitedco.org
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Alignment
Listed below are the current funding priorities for United Way of Deschutes County.
Please check those for which your program provides a significant response and for
which you are seeking United Way funding. If selecting multiple funding priorities,
please rank them by order of what your program addresses most strongly.
(i.e. 1-3 with 1 being the priority most strongly addressed by the program.)
EDUCATION:
___ Children enter kindergarten ready to succeed with health and development on track
___ Children are emotionally healthy and socially competent
___ Children graduate from high school
___ Young adults make a successful transition from high school to college and/or career
INCOME and SAFETY NET: - Lower income families and individuals
___ Have their basic needs met
___ Gain and/or maintain stable employment
___ Increase and/or retain income
___ Build and/or maintain savings and assets
HEALTH:
___ Children and families are safe and thriving
___ Children receive universal health screenings and follow-up to address identified issues
___ Individuals, families and youth receive the nutrition they require to be healthy and
productive
___ Families and Individuals receive basic health care coverage and health care services
___ Seniors and persons with disabilities are able to remain independent
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Narrative
Program description [500 characters maximum]:
How does this program address the funding
priority (or priorities) selected? [1800 characters
maximum]:
How many unduplicated individuals or
households do you anticipate will be served by
this program during the funding year? [specify
individuals or households in your answer]:
Program Impact
Is program considered best practice, evidence
informed, or evidence based, if yes explain. [500
characters maximum]:
Explain how this program will make a
sustainable and measurable impact. [1800
Do you have a plan for operating the program
after this funding period? Explain. [500
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Outcomes and Measurement
What are the inputs included in your program?
(program resources, elements or ingredients that
constitute the program) [1000 characters
maximum]:
What are the activities of your program?
(methods for providing the program; specific
processes or events undertaken) [1000 characters
maximum]
What are the outputs for your program? (units of
service; how many, how often, over what duration)
[1000 characters maximum]
What are the outcomes for your program?
(ultimate impacts expected to occur, usually beyond
what is achieved during the program process)
What indicator(s) will you use to measure your
effectiveness in reaching the desired
outcomes? [1000 characters maximum]
What tools will you use to measure data and
ensure it is consistent in both gathering and
reporting? [500 characters maximum]
Share the measured results you have collected
for this program in the last year. If UWDC
funded this program last year, use the work
plan from the previous year. [1600 characters
maximum]
*If this is a new program, please type “new
program” in the response section.
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Demographics
Report the unduplicated number of program participants by geographic area, gender, race/ethnicity, income level
and age group.
Participants by City
2016 Actual
2017 CY FY Expected
2018 CY FY Projected
Bend
La Pine
Redmond
Sisters
Sunriver
TOTAL
Circle Calendar Year (CY) or Fiscal Year (FY)
Participants by Gender
Gender
Participants by Age Group**
2016 Actual
Age Group
Female
0-5
Male
6-12
Gender Unknown
13-17
Total
18-24
2016 Actual
25-54
55-64
Participants by Race
Race
2016 Actual
American Indian/Alaska Native
Black/African American
Asian/Pacific Islander
65+
Unknown
Total
** if age categories do not align with your program you may
change them here.
Hispanic/Latino Origin
White/Caucasian
Other
Race/ethnicity unknown
Total
Participants by Income Level*
Income Level
2016 Actual Identified by
Low Income
Other Income Level
Unknown
Total
*Please identify how you determine income level. % of FPL, OHP, etc.
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Diversity and Inclusion
How do you continually ensure your program
services and staff are culturally competent in
regards to inclusion and diversity in all its
forms? (Race, class, religion, gender, sexual
orientation, ability, age, etc.) [500 characters
maximum]
Trauma Informed Care
Does agency/program have Trauma Inform Care
(TIC) policies and practices in place? Is
program staff aware of and/or trained in TIC?
Collaboration
How does this program collaborate/partner with
other service providers that address the same
issue? [800 characters maximum]:
Participants by Program Component
Does the program include multiple service components for which participants are tracked separately?
Yes ____
No____
If yes, list the program components in the table below and report the
number of participants served by each component. You may report up to three program components.
Program Component Description
2016 Actual Number Served
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Funding Request and Sustainability
Amount of Funding Request (Annual Amount):
Recent funding awards from UWDC rarely exceed
$30,000. If your request is over this amount, please
indicate how the funding would enhance your program
and its outcomes. [500 characters maximum]
If you don’t receive the full amount of funding
requested, how will that affect your program?
If awarded funds from UWDC, how will you sustain the
program beyond this funding cycle? [500 characters
maximum]
Program Staff
Describe your staff’s knowledge, expertise or abilities in
delivering this program. [500 characters maximum]
Co-Branding and Marketing
Please provide information about how you plan to promote your partnership with
UWDC.
Please give a brief description of your agency (approximately 15 – 25 words) and
description of your program (approximately 15 – 25 words). This information may be
used in UW promotional materials and referral resources.
To better publicize your agency and program, please explain how various dollar
amounts would impact your agency. What could people expect their annual gift to
buy if they donate $50, $100, $500, and an amount of your choice?
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Success Story
Please describe a success story for a
participant of your program from the last year.
(use the questions below to write the description)
 What issue was the program participant
experiencing?
 What services were provided to meet the needs
of the participant?
 What outcomes were achieved in the life of the
participant as a result of the services your
program provided
[1600 characters maximum]:
May United Way use this story in its
publications/website if your program is funded?
[ ] Yes
[ ] No
Document Checklist
Submit the items below along with your completed application no later than
to
United Way to Deschutes County
1130 NW Harriman Suite A Bend, OR 97703
PO Box 5969, Bend. OR 97708
 12 Copies of your proposal with budget page, paper clipped together
 1 copy of each of the following
 Most recent IRS Form 990/990EZ
 Current financial statements (Profit & Loss and Balance Sheet from your accounting software.)
 Organization’s current Financial Audit or Review
 Board of Directors Roster
 Anti-terrorism declaration
 Anti-discrimination declaration
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Application Form - United Way of Deschutes County

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