United Way of Western Connecticut

UNITED WAY OF WESTERN CONNECTICUT

Organization Fact Sheet

Organization Name:
Mailing Address:
City: / State: / Zip:
Phone #: / Fax #:
Website:
Executive Director: / Email:
Phone #:
Contact Person (if different): / Email:
Contact Person Title: / Phone #:
Board President: / Email:
Board President Address: / Phone #:

Organization Mission Statement: Please provide a brief statement of your organization’s mission.

Organizational Affiliations/Licensure/Certifications (please list as applicable):

Signature of Executive Director: ______Date:______

Signature of Board President: ______Date:______

Program Cover Sheet

Instructions:

Please complete a separate Program Cover Sheet each program for which you are seeking UWWC funding.

Program Name:
If program name has changed, please write in previous name:
Program Funding $ Amount Requested for Year One:
New or Existing Program In Agency:
Funded by UWWC Last Year (Yes or No):

Program Purpose/Outcomes:

Health programs focus on the ensuring of mental, physical, and behavioral health of children and adults in our region.

In considering the short, medium and long term outcomes of the program you are applying for, please check the long-term outcome listed below that best aligns with your program’s purpose. If you choose more than one outcome, please indicate with a #1 for the primary outcome:

Health Impact Area Long-Term Outcomes:

_____ People are mentally healthy

_____ Families are well and physically healthy

_____ People are safe and have healthy lifestyles

Program Narrative Questions

Instructions:

Please restate and answer all narrative questions listed below for each program for which you are seeking UWWC funding in the order they are presented in no more than four (4) pages. Font should be a minimum of size 10 with one inch margins on all sides.

1.  Describe the program that you are seeking funding for, please include in your description:

a.  the community issue this program seeks to address

b.  the target population served by the program

c.  best practices used to ensure effectiveness

d.  how the program provides services in a different manner or approach than similar services offered in the community or explain the need for multiple agencies performing similar services

2.  List your program outcome measures including results, please include:

a.  Program goals and results achieved for each outcome measure in your last fiscal year

b.  If a goal was not met, note any influencing factors discovered and program changes made in order to improve results for the next fiscal year

c.  Program goals and results you hope to achieve in the next fiscal year

3.  List key program partners and the specific roles they play, please include

a.  How your organization uses community resources (board members, volunteers, in-kind donations, corporate partnerships) to support the program

b.  How each partnership contributes to the success of the clients served

4.  Describe any significant staffing changes, restructuring or mergers that have occurred to the program or agency within the past year or may occur within the next year and how it may impact client services.

5.  How will UWWC funding contribute to the success of this program and its clients?

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