Application for Project Funding

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Project Name: __________________________________________________

 Agency Name: _________________________________________________

 Executive/Program Director:  _____________________________________

 Contact Person (if other than above):  _____________________________

 Mailing Address:  _______________________________________________         

 City:  _____________________________  State:  ____  Zip: ____________

 Phone:  _______________  Fax: _______________ Email:_______________

 Website:______________________________________________________       

 

 Brief synopsis of Project:

______________________________________________________________

______________________________________________________________

Project Start Date: __________ Project End Date: __________ Ongoing? __

 

Community Impact: Indicate which United Way priorit(ies) are impacted by the program/project for which funds are requested. If more than one, rank in order of impact (1 = greatest impact, etc.).

            __ Education: Early Literacy/School Readiness

            __ Education: Mentoring to At-Risk Youth

            __ Income: Literacy, GED or Job Training

            __ Income: Affordable Child Care (Full or Partial Day)

            __ Health: Basic Nutrition

            __ Health: Access to Mental Health Services

            __ Basic Needs: Direct Assistance to Individuals/Families in Need

            __ Basic Needs: Coordination of Services across Agencies

 

Counties Served: Indicate which counties will be served by the Program/Project.

 __ Ben Hill          __ Cook          __ Irwin          __ Tift          __ Turner

                                                                                                                

I am authorized to submit this Request for Funding on behalf of the above-named agency.

                                                                                       

Signature                                             

                                                                            

Name and Title (please print/type)


Funding Request 

1.    Name of Project: ___________________________________

2.    Amount Requested: $_____________

 

3.    Project Summary: Please provide a detailed summary of the project for which funding

is requested, including information such as target audience, plan to reach and engage the target audience, anticipated number of participants, nature of contact(s) with participants, names and examples of curriculum materials, etc.  Use additional page(s) as needed.

 

 

 

 

 

 

 

 

 

 

4.    Outcomes: Please provide a detailed list of intended outcomes, as related to the Community Impact Priorities indicated on the cover sheet, and plans for assessing the success rate in achieving each outcome. Use additional pages as needed.  Attach any relevant documentation.

 

 

 

 

 

 

 

 

 

5.    If the project was operational during either or both of the preceding two years, please indicate the number of unique individuals served in each county.

 

 


COUNTY


2012


2013


Ben Hill County


 


 


Cook County


 


 


Irwin County


 


 


Tift County


 


 


Turner County


 


 


 

 

6. Budget: Attach a detailed budget for the project.  Explain the proposed use of United Way funds within the budget. List all other income (sources and amounts) either received or requested for this project.

 

 

 

 

 

 

 

 

 

 

 

7. Sustainability: If the project is designed to continue after the period for which funding is requested, please explain how it will remain sustainable after requested United Way funds are spent.

 

 

 

 

 

 

 

 

 

 

 

 

8. Please provide any additional information that you wish to be reviewed by the Allocations Committee and/or United Way Board of Directors.