Application: Healthy Older Adults

Application: Healthy Older Adults

1.  Applicant information (maximum 1 page, minimum 11 pt. font)

Name of
Organization:
Organization Address:*
(street, city, state, zip)
Website:
CEO Contact (name):
Title:
Email Address
Phone #:
Name of Program/Project:
Select Service Types:
(one or more) /

___Nutrition ___Home and Community Based Services ___Caregiver Respite ___Other

Select Commission Districts: (one or more) /

___Commission District 1 ___Commission District 2 ___Commission District 3 ___Commission District 9

Program/Project Summary Description
(100 WORDS MAX)
*Program/Project Site Address:
(If different from org.)
Program Contact (name):
Title:
Phone #:
Email Address:
Total Annual Organization Budget:
Total Program/Project Budget:
Amount Requested from United Way:

*If program/project will be delivered at multiple sites, attach a separate sheet if necessary.

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2.  Organization information (THIS SECTION IS NOT TO EXCEED 1000 WORDS)

a.  Provide the agency’s mission and a brief description of its history of providing services.

b.  Describe the agency’s current programs including population served, geographic area and services provided. Please provide the number of clients served this previous year. Emphasize work relevant to older adult health, home and community supports, or other.

c.  Emphasize the organization’s qualifications and assets that would support the intended outcomes of this application.

3.  Target Population (THIS SECTION IS NOT TO EXCEED 1000 WORDS)

a.  Describe the specific target population(s) in the commission district(s) selected. Estimate the number of clients to be served.

b.  Describe the agency’s history of providing services to the target population. Include any specific knowledge, learning, or other relevant to providing the proposed services to this population.

c.  Describe the cultural competency of proposed staff (and partners if applicable).

4.  Proposed services (THIS SECTION IS NOT TO EXCEED 1500 WORDS)

a.  Provide a detailed description of the proposed services for clients

b.  Add details about the agency’s past experience providing these services.

c.  Please emphasize what’s special or unique about the proposed program (i.e. program innovations, evidence-based models, adaptations, leveraging assets, etc.)

5.  Outcomes and Results (THIS SECTION IS NOT TO EXCEED 500 WORDS; USE IT AS A COMPLEMENT TO THE “LOGIC MODEL AND MEASUREMENT FRAMEWORK” FORM)

a.  Complete the Logic Model and Measurement Framework (form provided) describing what the program’s inputs, activities, outcomes and indicators. (For guidance, refer to Project Scope and Logic Model Guide).

b.  Optional: Add additional narrative to complement the form, if needed (max. 500 words)

6.  Partner and stakeholder engagement (THIS SECTION IS NOT TO EXCEED 1000 WORDS)

a.  Use the grid below to provide a list of partners/key stakeholder you expect to engage. Attach a list if additional space is needed. Indicate with an ‘x’ in the last column if a relationship/engagement already exists.

PARTNER/STAKEHOLDER / ROLE RELATIVE TO YOUR PROPOSED PROGRAM / RELATIONSHIP STATUS

a.  If working with other community partners, describe why and how. Emphasize the extent to which you have already gained their support for the proposed program. Describe the benefits of the partnership as well as anticipated challenges (and how these will be mitigated or overcome).

b.  If engaging caregivers/families as a secondary stakeholder (and not as the main target population described in #3 above), describe why and how. Describe how you will ensure that engagement is successful and how it will impact the success of the proposed program and the outcomes for older adult clients.

7.  Financial Information (THIS SECTION IS NOT TO EXCEED 500 WORDS; USE IT AS A COMPLEMENT TO THE “BUDGET” FORM)

a.  Complete and submit the budget form provided (includes two tabs; one for the agency and one for the program).

b.  Required: Further explain the type, level, and rational for the staffing included in the program budget.

c.  Discuss the program’s ability to secure additional funding (if needed) and resources for program implementation.

d.  Describe the type, level, source and value of any in-kind resources (if applicable).

8.  Attachments
All applicants, please complete and attach the following forms (provided with the application):

a.  Agency and program budget (use the form provided)

b.  Logic model and measurement framework (use form provided)

Only for applicants who are not currently a United Way Impact Partner, please attach the following documents to the application:

c.  501(c)3 IRS tax exempt letter

d.  Most recent financial audit conducted by an independent auditor (no earlier than 2014)

e.  Management letter and response

f.  IRS form 990

g.  Board list

h.  Non-discrimination policy

i.  Agency Internal Control Questionnaire (this form is available online)

9.  Required signatures

(Agency name)
(Board Chairperson signature)
(Print name)
Date: /
(Chief Executive Officer signature)
(Print name)
Date:

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