NOTICE: All application materials must be in the Variety office by 5 p.m. on the application deadline (3/27/2015).Incomplete applications will be discarded and will not be considered for funding. No notification of missing items will be sent to agencies as in previous funding cycles.
Date:
Applicant:
(name as it appears on IRS determination letter; also include commonly used name if different)
Address:
StreetCityStateZip
EIN #: Agency Website:
Primary Contact (for this Application): Name and Title
EmailFaxPhone #
Signature of Agency DirectorDate
Signature of Board PresidentDate
1)Amount Requested(minimum $5,000):
2)In 100 words or less, give a brief description of your funding request:
3)Provide the mission statement of your organization as well as a brief description of your organization and its primary objectives. (250 word limit)
4)Number of Employees:
Full Time Part Time Total
5)Contact Person for questions
on financial information:NameEmailTelephone
6)Do you receive funding from the United Way? [ ] Yes[ ] No(If no, skip to question 7)
a)If so, is it designated for specific programs or general operations?
b)If designated for specific programs, has it been designated for the program for which you are requesting Variety funding? [ ] Yes [ ] No
7)Are you part of a national organization? [ ]Yes [ ] No (If no, skip to question 8)
a)If so, what percentage of your annual operating budget comes from national organization support?
b)What percentage/dollar amount of your annual operating budget is sent to the national organization?
c)What percentage of the money sent to the national organization is retained by the national organization (i.e. not transferred back to the local organization)?
8)Is your organization periodically reviewed by a licensing or reviewing agency? [ ]Yes[ ] No
a)If so, please list the accrediting agency(s):
9)Do you have a non-discrimination policy?[ ]Yes [ ] No
10)General financial information: Please provide information for your organization for the most recent audited fiscal year as well as the current annual budget. Please submit copies of your most recent audited financial statements as well as your most recent board-approved total organizational budget including percentage of total expenses by program, management & general, and fundraising. Your subsequent updated audit and financial information will be requested during the site visit which typically occurs between June and August.
a)Total organizational budget:
b)List the top five donors/funding sources for your organization:
c)What percentage of your budget is used for free care/services:
d)Do you receive government funding?
- If so, from what agency(s):
- What percent of your operating budget is government funding?
e)Do you have endowment funds? [ ] Yes [ ] No
If so,
Board Designated Endowment
Operating Reserve
Donor Designated Endowment
11)Program Description
Program Title:
Proposed Program Type (see grant guidelines for definitions). Please select ONE primary area for your program:
Therapy
Recreation
Equipment
Education
Sunshine Coach Van
Program Duration:
Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)
Is this request for a new or existing program/van?
Geographic area served by the program/van (please list counties):
12)Describe the proposed program, including general purposes, components of the program, and any significant partnerships with other organizations. If you are requesting a Sunshine Coach Van, describe how the van will be used with respect to transporting children with disabilities to Therapy, Recreation, Equipment, or Education services. (250 word limit)
13)Target Population
Total number of children who will be served by the program/van:
Total number of children with physical and/or intellectual disabilities who will be served by the program/van:
For the children with disabilities who will be served by the program/van, please provide the following demographic information:
Gender / Race/Ethnicity / Physical Disability / Intellectual Disability / AgeMale / African American / Cerebral Palsy / Autism Spectrum / 0-3
Female / Asian / Down Syndrome / ADD/ADHD / 4-6
Hispanic / Hearing Impaired / Behavioral Disorder / 7-12
Native American / Muscular Dystrophy / Intellectual Delay / 13-18
Caucasian / Spina Bifida / Pervasive Developmental Disorder / 19-21
Other / Visually Impaired / Other (please specify)
Other (please specify)
Total Number of Children Served
a)How are physical and/or intellectual disabilities in the children served identified? Please check all that apply.
Parent
Teacher (observation, anecdotal records, parent/teacher conference)
Physician
First Steps Program
Parents as Teachers Program
Therapist (Occupational, Physical, Speech/Language, etc.)
Social Worker
Counselor
b)What documentation supports the diagnosis? Please check all that apply.
IEP (Individual Education Plan)
Medical Records
Other (please specify):
14)Number of children who will be served through Variety funding support:
15)Number of units of service that will be provided through Variety funding support (include definition of unit of service):
16)How is the need for this program/van determined and how will this program/van respond to the needs? (250 word limit)
17)What are the expected specific outcomes/objectives for the program/van? Describe how Variety funds will be used to support Variety’s four core outcome priorities: skill development, increased independence, increased self-esteem, improved socialization. (250 word limit)
18)What specific qualifications does your organization and staff have to address these objectives? (150 word limit)
19)Describe the evaluation plan/tools your organization will implement to measure the expected outcomes including who will evaluate, expected dates of assessment, and criteria for judging success? (250 word limit)
20)Program Budget (If you are requesting a van, please answer the following questions using the budget for the program in which the van will be utilized)
a)What is the total budget for this program?
b)What is the budgeted cost per child for this program?
c)Is there a fee for participants of the program? [ ] Yes [ ] No If yes, how much?
d)What percentage of the total program budget does this funding request represent?
e)How will Variety funds be used? Describe the major expenditures necessary to successfully execute the proposed program and the financial resources the organization will use in support of the program. (150 word limit)
f)Will the program exist if Variety does not fund it? [ ] Yes[ ] No If yes, how?
g)List the top 5 donors/funding sources of the program?
h)Please provide a detailed program budget. Please specify donor for any individual, foundation, federation, or corporate gift over $1,000.
Budget time period (mm/dd/yyyy-mm/dd/yyyy):
Local Government
State Government
Federal Government
Individuals
Foundation
Corporation
Federation
United Way
Membership Income
Program Service Fees
Product Sales
Fundraising Events (net)
Investment Income
In-Kind Support
Other Revenue -
TOTAL REVENUE
Expenses / Total / Funded by Variety
Salaries & Benefits
Contract Services (consulting, professional, fundraising)
Occupancy (rent, utilities, maintenance)
Travel & Local Transportation
Equipment
Supplies
Insurance
Printing & Postage
Program Evaluation
Marketing & Advertising
Administration
Other Program Expense -
Other Program Expense -
Other Program Expense -
Other Program Expense -
Other Program Expense -
TOTAL EXPENSES
21)Do you have Sunshine Coach van(s): [ ] Yes[ ] No (If no, skip to item 22)
If so, please provide:
a)Automobile Liability Insurance Company:
b)Limit of Liability coverage:
c)Number of moving violations in the Sunshine Coach van(s) in the past year:
d)Total number of children transported in the Sunshine Coach van(s) in the past year:
e)Number of children with disabilities transported in the Sunshine Coach van(s) in the past year:
22)Please send one signed original and four copies of this application form and two copies of each of the following required documents. Please three-hole punch all documents. Do not include any unsolicited documents as they will not be reviewed and will be discarded or returned to you.
a)Audited financial statement of your most recent audited fiscal year including a balance sheet, income statement, and related footnote disclosure
b)A copy of your most recent 990
c)Updated financial documents will be requested at time of the site visit
d)Most recent board approved total organizational budget including percentage of total expenses by program, management and general, and fundraising
e)Copy of your Federal IRS tax exempt letter
f)Current Board of Directors list including titles and affiliations
g)Copy of your most recent Annual Report, newsletter, and brochure
23)When completed, please return to:Variety the Children Charity of St. Louis
Attn: Karen Haglin
2200 Westport Plaza Drive, Suite 306
St. Louis, MO 63146
REMINDER: All application materials must be in the Variety officeby 5 p.m. on the application deadline (3/27/2015). Incomplete applications will be discarded and will not be considered for funding. No notification of missing items will be sent to agencies as in previous funding cycles.
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