Application: Healthy Lifestyles

1.Lead 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 ofProgram/Project/ Collective Initiative:
Select Areas:
(Type ‘X’ before all that apply) /

__Healthy Eating __Physical Activity __Change in School Environment

__Other (describe):
Summary Description of Program/Project/
Collective Initiative
(e.g. the type and scope of what will be offered/ coordinated at the school, and projected benefits for target populations)
(100 WORDS MAX)
*Additional Sites:
(if applicable; see note below)
Lead’s Implementation
Contact (name):
Title:
Phone #:
Email Address:
Total Annual Organization Budget:
Total Program/Project Budget:
Amount Requested from United Way:

* Information about the partner school site will be captured in section 2. However, if key elements of your work will take place at other sites (e.g. parks), please include in this section.

2.Miami-Dade County Public School Information(MAX. 1 PAGE, MIN. 11 PT. FONT)

Name of School:
Required MOU Form (from MDCPS)is signed and attached to this application (Y/N): /

__YES __NO

INSTRUCTIONS: Access the online form in the RFP Tools section. Provide only 2 of 5 signatures: Lead Applicant will sign as “Agency” and school Principal will sign as “Principal.” All other signatures will be handled by MDCPS.
This form demonstrates that the Lead Applicant and Principal are working together; it confirms awareness offuture agreements required by MDCPS (in the event this application is successful).
Principal Name:
Principal Phone #: / Fax #:
Principal Email:
Website:
Street Address:
City, State, Zip:
Other Key Contact Name:
Title:
Phone #: / Fax #:
Email Address:
Grade Levels at School: / Region
Is this Site on the Recommended School List? /

__YES __NO

REFER to list online in RFP Tools.

Status/Availability of Items re MDCPS Wellness Policy
INSTRUCTIONS: Brief statements only (expand in section 4). Status will vary by school, but application should reflect an understanding of what’s in place. /

School Wellness Committee

Completion of School Health Index

School Health Inventory & Action Plan

Principals’ Wellness checklist

Other

Is the school currently enrolled as an Active school with the (national) Let’s Move! Initiative?__YES __NO (

3.Big Picture Outlook (THIS SECTION NOT TO EXCEED 1500 WORDS)

  1. What does a school-based “Culture of Health and Wellness” mean for your school?
  1. Describe the current culture at your school relative to health and wellness.(Current state)
  1. Strengths
  2. Current Challenges
  1. Please describe the vision for a “Culture of Health and Wellness” at the school.(Desired future state, Long-term)

4.People and Partners

Lead Agency(THIS SUB-SECTION NOT TO EXCEED 1500 WORDS)

  1. Provide the agency’s mission and a brief description of its history of providing services.
  1. Describe the agency’s current programsincluding population served, geographic area and services provided. Include the number of clients served this previous year.
  1. Please describe your most relevant workrelated to healthy eating, physical activities and/or changing school environments and the results achieved in the previous program year.
  1. Emphasize the organization’s qualifications and assets that would support the intended outcomes and the collective model/collaborative approach of this application. Include any experience leading or managing day to day collaboration among multiple partners in a collective effort)?
  1. Please describe if and how your agency is currently promoting and/or assisting families to enroll in Florida Kid Care(a key interest of The Parent Academy of MDCPS)?

School (THIS SUB-SECTION NOT TO EXCEED 1500 WORDS)

  1. If applicable, describe why and how you arecurrently working with the proposed school.
  1. Describe how the school is currently implementing the MDCPS Wellness Policy (8510) and how this will intersect with your proposed effort. Include ways your effort may leverage or support the School Wellness Committee, School Health Index, School Health Inventory and Action Plan (template), Principals’ Wellness Checklist, or other (Note: While it is anticipated that the extent to which these components are already developed and/or being implemented will vary significantly from one school to the next, it is critical that your proposed work not duplicate or supplant these MDCPS interests).
  1. Describe any current evidence-based practices (relevant to a culture of health and wellness, healthy eating outcomes, physical activity outcomes, or other) being implemented at the school site and if and how these will be integrated into your proposed effort.
  1. To what degree is the school currently utilizing the resources made available through The Parent Academy of MDCPS?
  1. Describe the extent to which you have gained the support of administrators, teachers, etc. for the proposed program/project/collective initiative. Include the type and level of staffing and leadership the school is committing to this effort. Include anticipated challenges and how these will be mitigated or overcome.
  1. Schoolspaces and in-kind contributions:

(i) List the spaces at the school (classrooms, library, cafeteria, gym, etc.) that will be made available to your program/project/collective initiative.

Type of Space / Description of Space/ Utilization
i.e.: Cafeteria / i.e.: Program participants will use school’s cafeteria for snacks and special events.

(ii) List the in-kind contributions the school will dedicate for use by the program. Itemize each in-kind contribution and provide information requested in chart below.

In-Kind Contribution / Description of Contribution / Estimated Dollar Value ($)
i.e. Equipment- Other Technology / i.e. Program participants use school’s computers for web-based curriculum for nutrition classes. / $8,100
Personnel Services
Printing & Reproduction
Other
Total Dollar Value / $8,100

Parents/Family (THIS SUB-SECTION NOT TO EXCEED 500 WORDS)

  1. If engaging parents and families, describe why and how. Describe how you will ensure that engagement is successful and how it will impact the success of the proposed program.

Other Community Partners

  1. Using the grid below, list any other partners/key stakeholders that will be a part of the collective effort proposed. Attach an additional sheet if additional space is needed. Briefly state the role of each. In the last column, indicate with an ‘x’ whether or not a relationship/engagement already exists.

PARTNER/STAKEHOLDER / ROLE RELATIVE TO YOUR PROPOSED PROGRAM / RELATIONSHIP STATUS
  1. Compliment the grid above with information aboutwhy and how you will partner. Describe how you will ensure that partnerships will successfully support the collectiveeffort proposed.(1000 WORD MAX.)

5.Target Population for the proposed effort(NOT TO EXCEED 1000 WORDS)

  1. Describe the specific target population. Estimate the number of clients to be served. If targeting a portion of students within a school, state the rationale for doing so.
  1. Highlight histories within the collective partnership that demonstrate experience and past successes in service the target population. Include any specific knowledge, learning, or other that demonstrate your group is equipped for success in working with this population.
  1. Describe the cultural competencies of key staff (e.g. language, skills, understanding of values, beliefs, etc.)

6.Design and proposed services (THIS SECTION IS NOT TO EXCEED 2000 WORDS)

  1. Summarize the overall design of your proposed effort.
  1. Describe the overall design of your proposed effort and the specific services or interventions for your target population. Include overall goal of the collective effort for the two-year grant period as well as key objectives/components, methods, etc.
  1. Please emphasize what’s special or unique about the proposed program (i.e. program innovations, evidence-based models, adaptations, etc.).
  1. How will this proposed program fit in with and/or be integrated with the current school schedule, activities, etc.?

7.Outcomes and Results (THIS SECTION IS NOT TO EXCEED 1500 WORDS; USE IT AS A COMPLEMENT TO THE “LOGIC MODEL AND MEASUREMENT FRAMEWORK” FORM)

  1. Complete the Logic Model and Measurement Framework (form provided online) describing the program’s inputs, activities, outcomes and indicators. (For guidance, refer to the online Project Scope and Logic Model Guide).
  1. Optional: Add additional narrative to complement the form, if needed (max. 1500 words).

8.Financial Information (THIS SECTION IS NOT TO EXCEED 1500 WORDS; USE IT AS A COMPLEMENT TO THE “BUDGET” FORM)

  1. Complete and submit the budget form(form provided online; note that the Excel document includes two tabs; one for the lead agency and one for the collective program).
  1. Required: Further explain the type, level, and rationale for thestaffing included in the program budget.
  1. Discuss the program’s ability to secure additional funding (if needed) and resources for program implementation.
  1. Describe the type, level, source and value of any in-kind resources (if applicable; note that you may refer to the grid of in-kind school support you provided in section 4).

9.Attachments

All Lead Applicants must complete and attach the following:

  1. Application (MS Word document)
  2. Agency and program budget (Excel document, see 2 tabs)
  3. Logic model and measurement framework (MS Word document)
  4. Letter of Commitment for each Key Partner listed
  5. Memorandum of Understanding – MDCPS Form (MS Word document; this only requires the signature of “Agency” (Lead Applicant) and “Principal” (school Principal) as all other signatures will be handled later by MDCPS staff).

All Lead Applicants who are not currently a United Way Impact Partnermust attach additional information.

  1. Most recent financial audit conducted by an independent auditor (no earlier than 2015)
  2. Management letter and response
  3. Non-discrimination policy

For “Not-for-Profit”organizations, please also attach the following:

  1. 501(c)3 IRS tax exempt letter
  2. IRS form 990
  3. Board list
  4. Agency Internal Control Questionnaire (this form is available online)

10.Required signatures

Lead Agency
(Board Chairperson signature (if Not-for-Profit)
(Print name)
Date:
School
______
(School Administrator signature)
______
(Print name) / (Chief Executive Officer signature)
(Print name)
Date:
(Administrator’s Title)
Date:

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