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InstructionsTo fill out:
Download application and open in Word. Submit one e-copy of application, impact story, agency biography and attachments to Jen
Butler at [email protected] Submit (10) hard copies of application, impact story, agency biography and attachments to
United Way of North Central Iowa by January 27, 2017 at 4:00 P.M. United Way of North Central Iowa will not accept applications delivered in person, by fax, or by e-mail after this date.
Applications should be paper clipped and three-hole punched. Applications should be sent to 2911 4th Street SE, P.O. Box 1465, Mason City, IA 50401.
For any questions or to request additional information, please contact Jen Butler, Community Impact Director, by phone at (641) 423-1774 or by e-mail at [email protected].
Required Application Attachments1. Agency Biography2. Agency Impact Story (if you are a new program, please provide a short narrative about how you
intend to impact a potential client)3. Program Budget (included in application is acceptable) 4. (1) copy of 501(c)(3) or documentation of non-profit status 5. (1) copy of most recent agency financial statement6. (1) Copy of most recent agency 990
Application Checklist
Ten (10) copies of application, three-hole punched, paper clipped Ten (10) copies Success Story, three-hole punched Ten (10) copies Agency Biography, three-hole punched Ten (10) copies Program Budget, either included in application or attached (1) copy of Board of Directors Roster (1) copy of 501(c)(3) or documentation of non-profit status (1) copy of most recent agency financial statement (1) copy of most recent agency 990
United Way of North Central IowaFY 2017-2018 Application Instructions
A
General InformationFull Legal Agency
Name Enter Agency Name
Street Address Click here to enter street address
City Enter City State Choose an item.
Zip Code Enter Zip Code
Agency Website Click here to enter text
Agency Executive Director Click here to enter text
Title Click here to enter title
Phone Number Enter phone number E-Mail Address Enter email
Contact Person (if different) Enter Contact Person here
Title Enter title
Phone Number Enter phone number E-mail Address Enter email
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United Way of North Central IowaApplication for Funding
FY 2017-2018
United Way of North Central Iowa Application for Funding FY 2017-2018
Program Narrative: This section of the application requires a description of the proposed program you are seeking funding. Please be specific and concise.
Program Name: Click here to enter program name
Amount Requested: Click here to enter amount requestedWas this program awarded funds
in the 2016 Community Impact Process or Venture Grants?
☐Yes If yes, how much was this program awarded?
☐No $Click here to enter award amount
Purpose of the Program: Briefly describe the purpose or the overall goal of the program. Please describe, in detail, all program services and activities in which program participants are engaged.
Click here to describe purpose
Program Need:Please describe the specific local needs/problems/gaps addressed by the program.Click here to describe program need
Identification of Need:Please describe how need described above was identified and how your program addresses the identified need. Please attach any relevant research or data used to identify need to your application.Click here to enter identification of need description
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United Way of North Central Iowa Application for Funding FY 2017-2018
Program Location: Please identify which United Way of North Central Iowa counties and associated zip codes will be served by the program. (Check all that apply)
Counties: ☐ Cerro Gordo ☐ Floyd ☐ Franklin ☐ Hancock☐ Kossuth ☐ Mitchell ☐ Winnebago ☐ Worth
Please estimate the number of clients served by the program in each of the areas you have selected above.Click here to enter county estimates
Program Target Population: Please describe the target population of the program, including the size and circumstances of the population from which the program participants are identified. Include relevant descriptions of demographics of the program participants, risk factors and community conditions affecting the target population, and any other relevant characteristics of the program target population. Click here to describe target population
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United Way of North Central Iowa Application for Funding FY 2017-2018
Impact Area: This section is designed to help you identify the United Way Impact Area best describes your program. Please select only one impact area.
☐ Education: Helping Children and Youth Achieve their Potential
☐ Income: Promoting Financial Stability and Independence
☐ Health: Improving Peoples Health
Education (Select all that apply) Income (Select all that apply) Health (Select all that apply)☐ Early Learning☐ School Readiness☐ Childhood Growth & Development☐ Reading Proficiency☐ Youth Growth & Development☐ After School Programing ☐ Mentoring☐ Career Education☐ On time High School
Graduation☐ Higher Education/Work &
Life Goals☐ Parent Engagement☐ Strengthening Families☐ Advocacy☐ Other *(Please explain
within column space below)
☐ Basic Needs☐ Employment☐ Housing☐ Childcare☐ Financial Literacy/Repairing
credit or Reducing Debt☐ Legal Assistance☐ Adult/Family Literacy☐ Job Retention/ Unemployment Prevention☐ Self-Sufficiency Attainment☐ Advocacy☐ Other *(Please explain
within column space below)
☐ Health Care Access☐ Mental/Emotional Health☐ Dental Health☐ Addiction Treatment☐ Physical Activity & Nutrition☐ Injury Prevention☐ Parenting Skills☐ Abuse/Neglect Prevention☐ Healthy Relationships☐ Safety/Well-being☐ Advocacy☐ Other *(Please explain
within column space below)
*‘Other’ Description: Describe why the program for which you are requesting funds fits in one impact area of Education, Income or HealthClick here to enter ‘other’ description
If you would like to discuss how your program touches the United Way of North Central Iowa Impact Areas not chosen as your program’s primary impact area, please do so here:
Click or tap here to enter text.
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United Way of North Central Iowa Application for Funding FY 2017-2018
Program Outcomes and Evaluations
What outcome(s) will your program achieve in support of the Impact area in which you are applying (Education/Health/Income)? Outcomes refer to the changes in the behaviors or condition of the participants based on what services were offered to them. (Example: Families will have increased their financial literacy.)
Click here to enter program outcomes
What methods of evaluation will be used to measure progress towards the outcome(s) listed above? Please explain how the program will determine whether intended outcome(s) were achieved. Describe:
(a) What indicators will be measured to indicate program success;(b) What specific measures (e.g., behavioral, self-report, etc.) will be used to assess each of
these outcome indicators;(c) At what point(s) in time these measures will be collected and; (d) How the data will be analyzed and interpreted to assess the success of the program
Click here to enter program evaluation narrative
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United Way of North Central Iowa Application for Funding FY 2017-2018
Program Collaboration
Please describe how the program connects and collaborates with other service providers and community organizations, if applicable. If collaboration with other service providers or community organizations does not currently exist, please describe any possibilities for future collaboration with other service providers. Please be as specific as possible.
Describe your program collaborations here
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United Way of North Central Iowa Application for Funding FY 2017-2018
Program Funding
Please provide a detailed breakdown of how United Way funding will be used for this programClick here to enter text
Please describe how this program would stand on its own if United Way funding is decreased or discontinued.
Click here to enter text
Please provide a detailed budget summary supporting the overall program costs. Click here to enter budget narrative, an excel sheet may be copied below
Please describe the long-term strategy and plan for sustainability of the program. Please include the agency’s long-term funding plan.
Click here to describe long-term strategy and plan for sustainability of the program
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United Way of North Central Iowa Application for Funding FY 2017-2018
Additional Information
Please include any other information you would like to include about the program.
Click here to enter additional information
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United Way of North Central Iowa Application for Funding FY 2017-2018
The undersigned hereby certify:
The information contained in this application, and various attachments, is accurate and correct to the best of my knowledge.
I further certify that our Board of Directors endorses this funding application and agrees to the requirements set forth in the Grant Application Requirements.
Executive Director (Please Print)
Signature
Date
Email Address
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Board Chair (please print)
Signature
Date
Email Address
