Form C: Proposed Program Budget CURRENT YEAR BUDGET PROPOSED YEAR BUDGET GRANT AMOUNT BUDGET 2017-2018 Program Budget Only Program Budget Only Requested UW $ Only PROGRAM REVENUE Support from Organization Program Fees Membership Dues Legacies and Bequests Investment Income Sales of Materials Special Events Government – Federal Government – State Government – County Government – Municipality Grants (Specify) Grant – United Way of Blair County Allocations – Other United Ways Misc. Revenue – Please list sources: TOTAL PROGRAM REVENUE PROGRAM OPERATING EXPENSES Salaries Employee Benefits Payroll Taxes, etc. Professional Fees Supplies Telephone Postage Occupancy Equipment Rental and Maintenance Printing/Publications Travel Professional Development Assistance to Individuals Membership Dues Share of Administrative Costs Misc./Capital Expenses – Please list if over $500 TOTAL PROGRAM OPERATING EXPENSES EXCESS (DEFICIT) REVENUE OVER TOTAL N/A N/A The review team will look at Form C in relationship to the financial reports provided for the organization as a whole. If there are variations please provide a brief explanation to clarify any differences. For example: the program shows a deficit on Form
United Way of Blair County Appendix 1: Summary of IMPACT FUNDING: A community plan _____________________________________________________ Summary of the United Way of Blair County Impact Funding: A Community Plan Page numbers help you locate this information in the IMPACT FUNDING: A COMMUNITY PLAN document available at www.unitedwayofblaircounty.org/impact-grants. Focus Area #1: Income, page 6 ESSENTIAL ELEMENTS ISSUE OBJECTIVES PAGE Education and Training Awareness Increase public awareness and utilization of community/county resources for job training & education. 6 Facilitate job training & education initiatives to match the economic vision of current & future job trends of the county. 6 Basic Budgeting Practices Assure that all children and adults in County are provided with basic budgeting courses. 6 Focus Area #2: Meeting Emergency Needs, pages 7-9 ESSENTIAL ELEMENTS ISSUE OBJECTIVES PAGE Basic Needs Lack of 24/7 Emergency Shelters and Education on Availability Assure that Blair County will have a sufficient number of “accessible” emergency shelter beds 24/7 for men, women, and children. 7 Lack of education and communication on how to access emergency services Assure the a one-call information center (PA 211) is able to provide an updated database that all Blair County residents can use to find the help they need. 7 Safe Shelter Assure that runaway and/or homeless youth, or youth and adults at risk due to family conflict, have access to the services and support they need. 8 Disaster/Emergency Services Lack of awareness of process of identifying individuals with special during an emergency Assure all people with special in Blair County can be identified/notified in an emergency. 8 Disaster Response Assure that all people have access to food, shelter, and clothing in of disaster/emergency. 9 APPENDIX 1, page 2
Focus Area #3: Education, pages 10-14 ESSENTIAL ELEMENTS ISSUE OBJECTIVES PAGE An ongoing relationship with a caring adult/older youth that promotes healthy beliefs and standards Mentoring Increase number of children or youth who are matched with an appropriate mentor. 10 Create and/or expand mentoring opportunities throughout Blair County. 10 Safe places and activities young people can learn and grow After-school Activities Increase the number and variety of after-school programs and/or increase participation in programs throughout Blair County. (Elementary to High School) 11-12 Safe neighborhoods Initiate and/or maintain programs and services that develop and sustain safe neighborhoods. 12 Childcare Increase the number of licensed, quality childcare slots throughout Blair County. 12 Increase the number of children from low and moderate-income families who receive subsidized childcare. 12 Appropriate life skills and job training opportunities Life Skills Support efforts to develop life skills of our children, youth and all members of the community in Blair County. 13 Parenting and Relationship Skills Increase measurable parenting skills through offering “best practice” parenting programs. 13-14 Decrease the risk factors and increase the protective factors as described in the Pennsylvania Youth Survey- Blair County (). 13-14 Enhance the family’s ability to support and nurture members. 13-14 APPENDIX 1, page 3 Focus Area #4: Health, pages 15-19 ESSENTIAL ELEMENTS ISSUE OBJECTIVES PAGE A safe, supportive, and stable nurturing environment in which families can thrive and grow Violence and Abuse Reduce the number of families in Blair County who are affected by violence and abuse. 15 Lack of affordable, quality care for older adults/Lack of knowledge about services Increase family knowledge of how to choose care. 15-16
S A M P L E F O R M United Way of Blair County Appendix 4: sample Logic Model Form A: Program Outcomes Model Worksheet Organization: To Your Health Program: Smoking Cessation Program Mission or Goal(s): To provide smokers who wish to quit smoking with the information, skills, and support to successfully reach their goal. Brief Description of Program: The smoking cessation course, taught over 8 weekly meetings of 1.5 hours educates smokers about the risks. Note: Please refer to “Appendix 2: Definitions of Terms for Measuring Program Outcomes” for additional information. Inputs Activities Outputs Initial Outcomes & Timeframe Indicators & Targets for Initial Outcomes Intermediate Outcomes & Timeframe Indicators & Targets for Intermediate Outcomes Long-term Outcomes & Timeframe Indicators & Targets for Long-term Outcomes -2 RNs -Educational materials (pamphlets, videos, kits) -Meeting space -Funding -Trained facilitators (past smokers) Program provides 8 weekly smoking cessation sessions which may include: Videos Guest Speakers Role Playing Meditation # of classes # of participants (initial) # of participants (ending) # of guest speakers Outcome: Participants gain knowledge about health hazards of smoking. Timeframe: Within two weeks of intake Outcome: Participants learn effective smoking cessation techniques Timeframe: Weeks 5 & 6 Indicator: # of participants who can identify 3 ways smoking negatively impacts health Target: 85% of participants Indicator: # of participants that can identify 2 effective cessation techniques that work for them. Target: 80% of participants Outcome: Participants change their attitude about smoking Timeframe: Weeks 6-8 Indicator: # of participants that report they are more likely to quit smoking now than when they started the class. Target: 75% of participants Outcome: Participants make plans to quit smoking Timeframe: Weeks 6-8 Outcome: Participants quit smoking. Timeframe: End of 8th session Indicator: # of participants who make plans to quit smoking within the next three weeks. Target: 75% of participants Indicator: # of participants who quit smoking by the end of the 8th session. Target: 60% of participants Constraints on Inputs: Participants must be willing to take risk to quit
APPENDIX 5: SUBMISSION CHECKLIST __Original Proposal __Cover Sheet signed by 501(c)(3) Applicant Executive Director and 501(c)(3) President/Chair of Board of Directors Complete Narrative __ I. Response to UWBC Impact Funding II. Program Explanation and Rationale __ A. Description __B. Goals and Rationale __C. Status III. Program Outcomes __A. Logic Model __B. Outcome Explanation IV. Program Service and Evaluation __ A. Eligibility Criteria __B. Evaluation V. Program Financials __A. Rationale __B. Proposed Budget and Budget Narrative __C. Supplementary/Sustaining Investment __8 Copies of Original Proposal, each copy three hole punched and bound by clip. ADDITIONALLY ONE COPY OF THE FOLLOWING DOCUMENTS MUST BE SUBMITTED: __Current list of Board of Directors __Most recent or Financial Statement __Most recent 990 __Appendix 5: Signed Submission Checklist __Appendix 6: Signed Anti-Terrorism Compliance Document __Appendix 7: Signed Anti-Discrimination Policy __Appendix 8: Signed 501(c)(3) Verification __Appendix 9: United Way Participation Checklist __A copy of your Internal Revenue Service 501(c)(3) Determination Letter All proposals must be received at the United Way of Blair County Office by 4:00 pm on Friday, March 17, 2017 – Mail or hand-deliver to: United Way of Blair County 5414 Sixth Avenue, Suite C Altoona, PA 16602 I certify that this application is complete and understand that missing items may result in the reduction of points. Signature of 501(C)(3) Executive Director Printed Name Date