New Program Questionnaire

Community Investment FY 18-19

Funding Period: July 1, 2017-June 30, 2019

Agency Name
Program Name
Physical Address
Mailing Address
Agency Phone
Agency Fax
Agency Executive Director
Email
Phone
Program Director
Name and Title
Email
Phone
Other Grant Contacts (if applicable)
Name and Title
Email
Phone

1.  Please provide a brief description of the program:

2.  Under which UWEM outcome do you plan to apply? (select one)

o  Outcome #1: Children enter school ready to learn and succeed. Target Population: Children under age six and their families.

o  Outcome #2: Children and youth increase assets and skills in order to increase their ability to accept and take personal responsibility, plan and make good choices, resist negative peer pressure and decrease vulnerability to dangerous situations. Target Population: Children & youth ages 5 to 18 and their families.

o  Outcome #3: Seniors live productive, active, healthy lifestyles and have the opportunity to age in place. Target population: Seniors and caregivers in Eastern Maine.

o  Outcome #4: Youth and adults have access to health education and preventative services to avoid risky behavior and achieve optimal physical and behavioral health. Target population: Youth and adults in Eastern Maine.

o  Outcome #5: People access services to achieve stability in their lives and maintain self-sufficiency. Target Population: Adults transitioning from crisis to self-sufficiency and those maintaining their self-sufficiency.

o  Outcome #6: Safety Net/Basic Needs and Crisis Intervention Programs: People access services to meet basic needs (food and short-term shelter) and crisis intervention (hot-line). Target Population: People needing basic need services, including Individuals, youth and families.

3.  Please provide a brief overview of how your program aligns with UWEM outcome?

4.  Do you meet the eligibility requirements as outlined in the application training and Community Investment Overview document? (check one)

o  Yes

o  No

5.  Have you or do you plan to attend a UWEM Outcomes Training and Application Overview Session?

o  Yes

o  No

6.  Is there anything else you would like to add?