Amount Requested: $_______________ In what areas of Broward County are services to be provided? (North, South, Central, or County-wide?) Or targeting zip codes with high rates of fetal/infant mortality and prematurity concentrated in several of the county’s zip codes. List of Zip Codes to be Served: ________________________________________________________________ Proposal Contact Person: _______________________________________ Phone Number: _______________________________________ _______________________________________ Name of Partner(s) or Sub-Contractors *if applicable ________________________________________________________________ APPLICATION FOR FUNDS Part I Section A. Applicant Agency Information: Cover Sheet Agency Legal Name must match Agency name listed on the Florida Department of State Division of Corporation website: Agency Legal Name: Main Administrative Address: City & State: Zip Code: Telephone Number: Fax Number: CEO/Executive Officer: Email: Office Phone Number: Financial Officer: Email: Office Phone Number: Agency Contact Person: Office Number:
families. (Limit to 150 words-approx. ¼ page) Relationships with support services that are available in Broward County are necessary for the success of a program. Describe other existing support services that are available in the community you plan to serve. Demonstrate your knowledge of those services and how your program will fit into that continuum of care. Describe the history of successful community collaboration. (Limit to 250 words-approx. ½ page) All agencies funded under this funding mechanism will be required to develop and implement a Cultural Competence plan. This plan must address culturally sensitive outreach efforts and human resource development. Discuss your commitment to a culturally competent system of care. Please attach your agency’s Cultural Competence plan. (Limit 250 words-approx. ½ page) Section C. Proposed Staff Information Describe how the program will be staffed. List all positions that will be providing direct and support services. Include the number of Staff in each position, position title (which should match your budget narratives), minimum education (including degree area), experience requirements, primary duties, and the percent of each position’s time that will be devoted to this program. Service Provider requirements for Healthy Start Services are outlined in the Healthy Start Standards and Guidelines (available at ) NOTE: Add or delete rows as necessary. # of Positions Position Education Experience Duties % of Time Devoted to Position Please include a timeline for hiring and training of that ensures services will be fully operational by October 1st, 2018. (Limit 250 words-approx. ½ page) Identify strategies to efficiently recruit staff that will be linguistically and culturally competent to serve the English, Spanish and Creole-speaking populations residing within these zip codes. Describe the organization’s practices supervising staff and knowledge on reflective supervision. Consistency is important to the success of services. Explain what efforts you will make to maintain staff and reduce turn-over of trained, experienced staff within the program. Include historical turnover information for your organization and current staff recruitment and retention efforts. (Limit 250 ½ page) Part III Section A. Additional ITN Application Requirements Client engagement and retention is a strong indicator of success. The ITN provides guidelines for Best Practices and non-traditional settings. Describe the organization’s protocols to achieve a high rate of acceptance rate and strategies for engaging and maintaining clients during the required services periods. Explain in detail how you plan to engage, retain clients in services and include innovative practices in this section. (Limit 250 words-approx. ½ page)