COLLABORATION GRANTS | SUMMARY PAGE
Please complete thisSummary Page for your grant request. If you have any questions relating to the submission of this page,please contact Tap Bui at Application, Summary Page and attachments are due by 11:59 p.m. Central Time on August 29, 2016. NO LATE submissions will be accepted. Submit on-line to only.
CONTACT INFO /- Fiscal Agent’s Name: Click here to enter text.
- Fiscal Agent’s Address:Click here to enter text.
- Fiscal Agent’s Website:Click here to enter text.
- Contact Person’s Name:Click here to enter text.
- Contact Person’s Address:Click here to enter text.
- Contact Person’s Email:Click here to enter text.
- Federal Tax ID #:Click here to enter text.
COLLABORATIVE /
- Total number of stakeholders involved in collaborative:Click here to enter text.
- Total number of formal partnerships in place with key stakeholders (if applicable):Click here to enter text.
- Total number of leadership and/or staff dedicated to the collaborative:Click here to enter text.
FUNDING & BUDGET /
- Total fiscal agent’s budget:Click here to enter text.
- Annualcollaborative budget (if applicable):Click here to enter text.
- Grant amount requested from UWSELA: Click here to enter text.
ATTACHMENTS /
- Please refer to the Attachments Checklist to ensure all relevant documents are submitted.
GEOGRAPHY
(select all that apply) / ☐Jefferson Parish
☐Orleans Parish
☐Plaquemines Parish
☐St. Bernard Parish / ☐St. Tammany Parish
☐Tangipahoa Parish
☐Washington Parish
OUTCOME FOCUS
(select all that apply; see grant guidelines for population-level indicators) / ☐Stability Today (all families have the skills, resources and opportunities to access basic needs)
☐Prosperity Tomorrow (all families have the social, educational, and financial assets to create a better future)
☐Personal Wellness (people of all ages enjoy a high quality of life and wellbeing)
☐Vibrant Communities (all communities are safe, thriving, and equitable)
GRANT TYPE
(see grant guidelines for grant type descriptions) / ☐Planning
☐Implementation / ☐Infrastructure
☐Continuous Improvement
HISTORY & MISSION / Describe the history and mission of the collaborative (250 word max)
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GRANT PURPOSE / Briefly describe the grant purpose, including beneficiaries served, as well as how the proposed work aligns with the funding request and contributes to the outcome focus.(500word max)
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