2017 read, tutor, mentor
Application for Funding Background Checks

For Internal Office
Use Only
Date Received: ______
Time Received:______
Staff Initials: ______
DEADLINE:
June 30, 2017 at 4:30PM EST

Applicant Summary:

  1. Agency or Program Name:Click here to enter text.
  1. EIN Number: Click here to enter text.
  1. Mailing Address, City, State, and Zip:

Click here to enter text.

Phone: Click here to enter text.

  1. Name of CEO or Executive Director: Click here to enter text.

Phone: Click here to enter text. E-mail: Click here to enter text.

Person(s) managing program(s) if not CEO/Executive Director:Click here to enter text.

Title: Click here to enter text. Phone: Click here to enter text.

Email: Click here to enter text.

  1. Name of Financial Representative: Click here to enter text.

Phone: Click here to enter text.Email: Click here to enter text.

  1. Is your program a school organization OR a 501(c) 3 tax exempt organization and in good standing with the Kentucky Secretary of State? Yes No
  1. Attach a copy of either your most recent Year End Balance Sheet ORIRS Form 990/990NORAudited Financial Statements.
  1. Please certify by checking each box and read entire instructions before completingapplication.

Type of program: Reading Tutoring Mentoring
My program(s) services one or more of the following UWCK Counties (please check all that apply): Breckinridge Grayson Hardin LaRue Meade
Email a copy of the completed application to .
  1. Amount of funding requested (max amount is $500): Click here to enter text.
  1. Please provide a brief description of your program and the desired outcome.
    Click here to enter text.
  1. Describe in detail how the funds you are requesting from UWCK will be used. Be specific about the types of background checks required, cost, how many volunteers it will cover, etc.

Click here to enter text.

  1. Describe the target population(s) this program serves. The target population identifies who will change as a result of the program’s intervention. Briefly explain how constituents enter and exit the program and describe your program’s constituents (age, gender, race, needs, risk factors, etc. as relevant), the conditions they face, and a general profile of their strengths and challenges.

Click here to enter text.

  1. Do you currently have a waiting list of children who are waiting to be matched with a volunteer? If so, how many?

Click here to enter text.

Proposed Results

  1. Number of unduplicated clients in UWCK’s service area anticipated to receive services: Click here to enter text.
  1. Each program must have at least one Indicator of performance, a target result, and brief description of how this objective will be measured. Programs are welcome to submit multiple Indicators if these results align with your work. Progress will be measured through 2 bi-annual online reports consisting of fewer than 10 questions. A report template will be provided upon the award of funding.
  1. Indicator #1: Choose an item.

Target Number: Click here to enter text.

How Measured: Click here to enter text.

  1. Indicator #2: Choose an item.

Target Number: Click here to enter text.

How Measured: Click here to enter text.

  1. Indicator #3: Choose an item.

Target Number: Click here to enter text.

How Measured: Click here to enter text.

  1. Indicator #4: Choose an item.

Target Number: Click here to enter text.

How Measured: Click here to enter text.

Submission Process Acceptance and Understanding:

Submit a copy of the application, Memorandum of Agreement with original signatures, and supporting financial document to the UWCK office by 4:30PM EST on June 30, 2017. Please email an additional copy of the application to by this deadline.

By requesting UWCK funding, the undersigned have carefully read the application, Memorandum of Agreement, and reviewed the information contained in this proposal for accuracy and completeness. We further understand that an incomplete application or failure to provide the information requested, as well as late submission, will render the submission as non-qualifying and ineligible for funding or further consideration in this funding cycle.

The undersigned also understands that this grant submission is currently implemented as an annual meritocracy and is not a long-term funding agreement. If funding is awarded, the applicant understand that funds must only be used for purchasing background checks for volunteers of the above mentioned program.

The undersigned also understand thata Memorandum of Agreement (MOA) must be signed by authorized personnel within your agency and returned with your application for it to be passed on to the Community Investment Team for review.

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Chief Volunteer/Board ChairDate

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Executive Director Date

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