FY15-18 Application for Continuing Activities

Activity Title

Agency/Organization Applying for Funding

Name of Agency/Organization:
Mailing Address:
Physical Address:
E-mail: / Phone: / Fax:
Type of Organization: / ( ) Private non-profit 501c3 ( ) Public ( ) For Profit
Federal Tax ID: / Agency Fiscal Year:
Contract Administrator Information
Name of Person Authorized to Administer Contract/Title:
Address:
E-mail: / Phone: / Fax:

Contract Signer Information

Name of Person Authorized to Sign Contract/Title:
Authorizing Agency/Organization:
Address:
E-mail: / Phone: / Fax:

Finance Contact Information

Name of Finance Person/Title:
Address:
E-mail: / Phone: / Fax:

Smart Start Funds Requested

/ $
Contract Signer
Signature: / Title: / Date:

A.  Need Statement

Describe the need to be addressed by this activity, including local data. Describe the current demand for your services and the level of need addressed by your activity (limit to one page)

B.  Service Description:

Please address the following:

·  specific services to be offered, required staff and any proposed expansion or modification for the three year funding period

·  population to be served, including eligibility criteria, recruitment strategies and retention strategies (if applicable)

·  use of an evidence based or informed program, practice or model

·  collaborative partners and how the activity fits into the local service continuum

·  activity’s major successes, challenges and lessons learned

·  percentage of FY14-15 program budget that is Smart Start-funded. Please include the require in-kind and cash contributions in your calculations

·  any one-time critical needs requests that would enhance your activity during the three year funding period (must match budget narrative)

C.  Results:

Participants to be served e.g. # of children, families, centers (insert lines as needed)

Annual Goal / FY15-16 / FY16-17 / FY17-18
Example: 100 children served

Services to be provided e.g. # of home visits, training sessions, referrals (insert lines as needed)

Annual Goal / FY15-16 / FY16-17 / FY17-18
Example: 100 home visits conduced

List all evaluation tools that you use (pre/post tests, client surveys, observation forms, etc.)

Create a minimum of one outcome for each evaluation tool referenced above for each of the three fiscal years (add tables as needed)

FY15-16

Outcome 1 (#/%):
Population or sample description:
Measurement Tool:
Is the tool connected to a model or curriculum?
Definition of Success:

FY16-17 & FY17-18

Outcome 1 (#/%):
Population or sample description:
Measurement Tool:
Is the tool connected to a model or curriculum?
Definition of Success:

D.  Budget: (See Budget Narrative FY15-18 EXCEL form)

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As a separate attachment - list ideas for additional related services that might benefit your target population.