united way of volusia-fl...ies, inc - google forms€¦ · web view · 2015-01-21pacesetter...

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PLEASE NOTE: THIS IS NOT THE OFFICAL APPLICATION. IT IS A WORKSHEET FOR YOUR ORGANIZATION TO USE TO PRE-PREPARE YOUR ANSWERS BEFORE ENTERING THEM INTO THE ONLINE SYSTEM. IT IS RECOMMENDED THAT YOU KEEP A COPY OF THIS DOCUMENT FOR YOUR RECORDS.

United Way of Volusia-Flagler Counties, IncFunding Application for Fiscal Year 2015-2016

*Required

1. Agency Name *

2. DBAAgency DBA

3. HQ Address *Headquarters Street Address

4. HQ City *Headquarters City

5. HQ State *Headquarters State -2-letter Abbreviation

6. HQ Zip *Headquarters Zip Code

7. Local Address *Local Street Address

8. Local City *Local Address City

9. Local State *Local State - 2-letter abbrevation

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10. Local Zip *Local Address Zip Code

11. Contact Name *

12. Contact Email *

13. Contact Phone *

14. FY Begin *Beginning Date of Fiscal Year

Example: 1 2 / 15

15. FY End ff

Ending Date of Fiscal Year

Example: 12 / 15

16. Federal ID Number *

17. ED Name *Executive Director

18. ED Address *Executive Director Street Address

18. ED City *Executive Director’s City

19. ED State ff

Executive Director State - 2-letterAbbreviation

20. ED Zip *Executive Director Zip Code

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21. ED Phone *Executive Director Phone Number

22. Board Chair *Board Volunteer Chair Name

23. Chair Address *

24. Chair City *

25. Chair State *

26. Chair Zip *

27. Chair Phone *

I. AGENCY INFORMATION/OVERVIEW

28. Agency Description *General Description of Agency (50 words maximum)

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29. Mission *Agency Mission Statement

30. Vision *Agency Vision Statement

31. History *Brief History (date established, etc.)

32. Services *Services Provided by Agency

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33. Delivery *How Are Services Provided?

34. Target *Geographic Area of ServiceCheck all that apply.

___ Flagler County

___ Volusia County

___ Both Flagler and Volusia Counties

___ Flagler, Volusia, & Other Counties

II. PURPOSE OF AGENCY

35. Needs Met *Describe the community need(s) being met by your agency servicesCheck all that apply.

___ Education ___ Income ___ Health ___ Basic needs (food, shelter, clothing, financial assistance)

36. Needs Explanation *Explain Needs Being Met

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37. Changes/Challenges *Check any significant changes and/or challenges that occurred in the last year.Mark only one oval.

___ Change of chief executives (finance officer, director, etc.)

___ Significant loss of federal funding

___ Significant loss of state funding

___ Elimination of significant program or activity

___ Findings listed in annual agency audit

___ No significant changes or challenges

38. Changes Explanation *Please explain significant changes noted above with program, funding, findings, corrective measures. If none, please type N/A.

39. Successes *Please discuss agency successes.

Ill. Board of Directors

40. Board Local *Do you have a governing Board of Directors with local representation?Mark only one oval.___ Yes___ No

41. GovernanceIf you answered "no" above, please describe your system of governance (i.e., chapter of national Organization with local advisory board, local advisory board has representation on larger regional Board of Directors, program is part of public entity, etc.

42. Meeting Frequency 11

How often did the governing body meet during the last calendar year?Mark only one oval.

___ Monthly

___ Bi-Monthly

___ Quarterly

___ Less than Quarterly

43. Frequency DetailsIf meeting less than quarterly, please explain.

44. Attendance *Describe the average meeting attendance.Mark only one oval.

___ Only minimum number of attendees to achieve a quorum

___ At least 25% of the appointed board



IV. AGENCY FUNDING SUMMARY

45. Matching Funds 11

Does your agency receive matching funds?Mark only one oval.

___ Yes

___ No

46. If yes, what is the match ratio?Identify the match ratio for any grant that is leveraged. For example, the return is $4 per $1 raised locally.

The match ratio is 1:4.

Fundraising

Indicate what percentage the following efforts comprise your total fundraising efforts.

47. Special Events *Mark only one oval.

___ 0%

___ 1-25%

___ 26-50%

___ 51-75%

___ more than 75%

48. Raffles *Mark only one oval.

___ 0%

___ 1-25%

___ 26-50%

___ 51-75%

___ more than 75%

49. Direct Solicitation *Mark only one oval.

___ 0%

___ 1-25%

___ 26-50%

___ 51-75%

___ more than 75%

50. Grants *Mark only one oval.

___ 0%

___ 1-25%

___ 26-50%

___ 51-75%

___ more than 75%

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51. Other *Mark only one oval.

___ 0%

___ 1-25%

___ 26-50%

___ 51-75%

___ more than 75%

52. Agency-generated revenues *Check all that apply.

___ Per Client Fee

___ Fee for Service

___ Memorials

___ Sale of material or product

___ Other.

V. AGENCY FINANCIAL OVERVIEW

53. Agency Financial Narrative *AGENCY FINANCIAL NARRATIVE: The narrative should help the reader understand how your budget aligns with program services. Include information about: In-kind revenues received and the value of such in-kind items. Agency-generated revenues (fee for services sliding scale, per client fee, special events, memorial). United Way contributions, whether one, two, or multi-county. Budgetary shortfalls. Any reserves as they relate to organizational shortfalls and viability. Identify any significant financial changes experienced by the agency and reflected in the budget financial data between Prior Year Actual and Current Year Projection, AND between Current Year Projection and Proposed Year.

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In-Kind Revenues

Check all that apply regarding in-kind revenues that are received and the value of such in-kind items annually.

54. Legal Services •Mark only one oval.

___ 0

___ $1-$2,500

___ $2,501-$5,000

___ $5,001-$15,000

___ Greater than $15,000

55. Advertising/Marketing Services *Mark only one oval.

___ 0

___ $1-$2,500

___ $2,501-$5,000

___ $5,001-$15,000


56. Financial Services *Mark only one oval.

___ 0

___ $1-$2,500

___ $2,501-$5,000

___ $5,001-$15,000


57. Office Real Estate •Mark only one oval.

___ 0

___ $1-$2,500

___ $2,501-$5,000

___ $5,001-$15,000


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58. Volunteers *Mark only one oval.

___ 0

___ $1-$2,500

___ $2,501-$5,000

___ $5,001-$15,000


59. Other *Mark only one oval.

___ 0

___ $1-$2,500

___ $2,501-$5,000

___ $5,001-$15,000


60. Other UW Contributions *Is your agency receiving any contributions from other United Ways?Mark only one oval.

___ Yes

___ No

61. Other UW DetailsIf yes, please explain

62. Budgetary Shortfalls *Discuss any budgetary shortfalls:Mark only one oval.

___ Minimal - less than 6% of operating/program budget, no program impact

___ Minor -less than 10% of operating/program budget, minimal program impact

___ Moderate- greater than 10% of operating/program budget, moderate to significantprogram impact

___ Significant- greater than 15% of operating/program, unable to operate program atprior year levels and program in danger of elimination

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63. Shortfall Explanation *Explain the above shortfalls. If none, please type N/A.

64. Reserves Used *Discuss any reserves as they relate to organization shortfalls and viability

___ No use of reserves

___ Use of reserves for non-recurring expenses

___ Use of reserves for reoccurring expenses (i.e., operational and salary needs)

___ Reserves used regularly to fund program operating costs and salaries- not able toprovide programming without this funding source

65. Reserves Explanation *Explain the above use of reserves. If none, please type NIA.

66. Financial Changes *Identify any significant (10% or $2,500, whichever is greater) financial changes experienced by the agency and reflected in the budget financial data between Prior Year Actual and Current Year Projection AND Current Year Projection and Proposed Year

___ Salaries

___ Utilities

___ Professional Services

___ Insurances (not employee benefits)

___ Specific Program Expenses

___ None

___ Other:

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67. Financial Changes Explanation *Explain the above financial changes. If none, please type N/A.

68. Allocation Panel *List recommendations/comments made by last year's allocation panel as stated in the award letter.

69. Recommendations Changes *List changes made and results due to the recommendations/comments from the allocation panel.

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2014-2015 AGENCY SELF-EVALUATIONRelationship with United Way

70. Agency Agreement *The board understands and approves the United Way Agency AgreementMark only one oval.___ Yes

___ No

71. Fundraising Policies *The agency is knowledgeable of and follows United Way fundraising policiesMark only one oval.___ Yes

___ No

72. Internal Fundraising Campaign *The agency conducts an internal United Way fundraising campaign among its employeesMark only one oval.

___ Yes

___ No

73. PaceSetter AgencyIf agency conducted internal fundraising, was agency a PaceSetter, finishing the Campaign prior to the United Way Campaign Kick-Off?Mark only one oval.___ Yes

___ No

74. Speakers Provided *Did the agency provide speakers for United Way Campaign presentations?Mark only one oval.___ Yes

___ No

75. Council of Agency Executive Meetings *The agency director attends Council of Agency Executives meetings.Mark only one oval.___ Yes

___ No

76. Agency Representation *The agency is represented at United Way events and fundraisers (i.e., Campaign Kick-Off, Race Parking, Positive Picketing, etc.)Mark only one oval.

___ Yes

___ No

77. United Way Logo *

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The United Way logo is displayed on the agency's building, website, brochures, publications, and other marketing materials.Mark only one oval.

___ Yes

___ No

78. Outcome Measurement Training *Staff representative(s) from the agency attended an Outcome Measurement TrainingMark only one oval.___ Yes

___ No

79. Grant Workshop *Staff representative(s) from the agency attended the Grand Workshop for the FundingApplicationMark only one oval.___ Yes

___ No

80. Self Evaluation CommentsPlease share any comments you have regarding your relationship with United Way with regard to the self evaluation questions listed above.

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PROGRAMS

81. Program Total *Total Amount Requested for Programs in thisApplication

82. P1 *Program One Name

83. P1 Amount *Amount Requested

84. P2Program Two Name

85. P2 AmountAmount Requested

86. P3Program Three Name


88. P4Program Four Name


90. P5Program Five Name


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92. P6Program Six Name


SECTION 2: PROGRAM INFORMATION

94. P1 Name • Program Name

95. P1 Service Area *Please select ONE Service Area that BEST describes the impact focus of this program. Service areas will be used to report back to United Way donors.Mark only one oval.

Education

___ Income

___ Health

___ Basic Needs

96. P1 Description *Provide a short description of this program (50 words maximum)

97. P1 Needs *What are the needs in our community for this program's services?

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98. P1 Addressing *How are you addressing the need for services?

99. P1 Impact *What is the long term impact to the clients and to the community?

100. P1 Matching *Does the program receive matching funds?Mark only one oval.___ Yes

___ No

101. P1 Matching SourceIf matching funds are received, indicate the funding source.

102. P1 Match RatioIdentify the match ratio for any grant that is leveraged. Identify the cap on any leveraged grant. For example, the return is $4 per $1 raised locally. The leverage of 1:4 is up to a capof $50,000 (i.e. $50,000 brings in a maximum of $200,000).

103. P1 Grant *Was a grant requested last year?Mark only one oval.___ Yes

___ No

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104. P1 Increase Request *Was a funding increase requested?Mark only one oval.___ Yes

___ No

105. P1 Client Fees *Were there client fees? Mark only one oval. ___ Yes

___ No

106. P1 Clients Served *Number of clients served (UnduplicatedServices) (2014-2015 Projection)

107. P1 Cost/Client *Cost/client (in$)(# of clients served, unduplicated, divided by total program cost) (2014-2015 Projection)

108. P1 Locations *List separate locations for Program

109. P1 Days *Days of Operation

110. P1 Hours *Hours of Operation

111. P1 Staff *Number of staff

112. P1 Volunteers *Number of volunteers

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I. PROGRAM OVERVIEW

113. Prog 1 Changes *Has this program had a major change in the facilities, staff, or services in the past 12 months?Mark only one oval.___ Yes

___ No

114. Prog 1 Change CommentsIf yes, please explain the change and impact on the program.

115. Prog 1 New ProgramIf you did not previously request a grant for this program, is it a new program for your agency?Mark only one oval.___ Yes

___ No

116. Prog 1 AgeIf this is not a new program, how long has it been in existence?

117. Prog 1 Collaboration *Give examples of collaborative efforts regarding this program. DO NOT INCLUDE RELATIONSHIPS FOR CLIENT REFERRALS ONLY.

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118. Prog 1 Fees *Are client fees charged for this program?Mark only one oval.___ Yes

___ No

119. Prog 1 Fee RangeIf yes, what is the range of fees, and how are these fees determined?

120. Prog 1 Fee WaiverIf fees are not charged, why not?

121. Prog 1 Client Eligibility *How is client eligibility determined for this program?

122. Prog 1 Wait List *Describe the waiting list for program services (include the length of the list and how it is managed).

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II. PROGRAM DEMOGRAPHICS SUMMARY

Please complete the following questions summarizing the demographic characteristics of clients served by this program. If there are no prior year clients choose N/A. Do not use percentage; put actual numbers of clients. PLEASE NOTE THAT THESE FIGURES ARE NUMBERS OF CLIENTS SERVED- UNDUPLICATED, NOT NUMBER OF SERVICES PROVIDED.

AGE GROUP - 0-5

123. P1 0-5 Prior Yr •Prior year clients aged 0-5 (actual) 07/13-06/14

124. P1 0-5 Current Yr *Current year clients aged 0-5 (projected)07/14-06/15

125. P1 0-5 Proposed YrProposed year clients aged 0-5 (projected)07/15-06/16

AGE GROUP 6-10

126. P1 6-10 Prior Yr •Prior year clients aged 6-10 (actual) 07/13-06/14


128. P1 6-10 Proposed Yr *Proposed year clients aged 6-10 (projected)07/15-06/16

AGE GROUP 11-17

137. P1 30-54 Proposed Yr *

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129. P111-17 PriorYr *Prior year clients aged 11-17 (actual) 07/13-06/14

130. P111-17 Current Yr *Current year clients aged 11-17 (projected)07/14-06/15

131. P1 11-17 Proposed YrProposed year clients aged 11-17 (projected)07/15-06/16

AGE GROUP 18-29

132. P118-29 Prior YR *Prior year clients aged 18-29 (actual) 07/13-06/14

133. P118-29 Current Yr *Current year clients aged 18-29 (projected)07/14-06/15

134. P118-29 Proposed Yr *Proposed year clients aged 18-29 (projected)07/15-06/16

AGE GROUP 30-54

135. P1 30-54 Prior Yr *Prior year clients aged 30-54 (actual) 07/13-06/14


137. P1 30-54 Proposed Yr *

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Proposed year clients aged 30-54 (projected)07/15-06/16

AGE GROUP 55-64

138. P1 55-64 Prior Yr *Prior year clients aged 55-64 (actual) 07/13-06/14


140. P1 55-64 Proposed Yr *Proposed year clients aged 55-64 (projected)07/15-06/16

AGE GROUP 65+

141. P1 65+ Prior Yr *Prior year clients aged 65 and over (actual)07/13-06/14

142. P1 65+ Current Yr *Current year clients aged 65 and over(projected) 07/14-06/15

143. P1 65+ Proposed Yr *Proposed year clients aged 65 and over(projected) 07/15-06/16

AGE GROUP UNDOCUMENTED

144. P1Undocumented Prior Yr

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Prior year clients age undocumented (actual)07/13-06/14

145. P1 Undocumented Current YrCurrent year clients age undocumented(projected) 07/14-06/15

146. P1 Undocumented Proposed YrProposed year clients age undocumented(projected) 07/15-06/16

GENDER GROUP -Male

147. P1 Male Prior Yr *Prior year clients Male (actual) 07/13-06/14

148. P1 Male Current Yr *Current year clients Male (projected) 07/13-06/15

149. P1 Male Proposed YrProposed year clients Male (projected) 07/15-06/16

GENDER GROUP -Female

150. P1 Female Prior Yr *Prior year clients Female (actual) 07/13-06/14

151. P1 Female Current Yr *Current year clients Female (projected) 07/14-06/15

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152. P1 Female Proposed YrProposed year clients Female (projected)07/15-06/16

GENDE R GROUP -Undocumented

153. P1 Undocumented Prior YrPrior year clients Undocumented (actual)07/13-06/14

154. P1 Undocumented Current Yr * Current year clients Undocumented (projected) 07/14-06/15

155. P1 Undocumented Proposed YrProposed year clients Undocumented(projected) 07/15-06/16

ETHNI C BACKGROUND - Caucasian

156. P1 Caucasian Prior Yr *Prior year clients Caucasian (actual) 07/13-06/14

157. P1 Caucasian Current Yr *Current year clients Caucasian (projected)07/14-06/15

158. P1 Caucasian Proposed Yr *Proposed year clients Caucasian (projected)07/15-06/16

ETHNIC BACKGROUND- African-American

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159. P1African-American Prior Yr *Prior year clients African-American (actual)07/13-06/14

160. P1African-American Current Yr *Current year clients African-American(projected) 07/14-06/15

161. P1African-American Proposed Yr * Proposed year clients African-American (projected) 07/15-06/16

ETHNIC BACKGROUND- Hispanic

162. P1Hispanic Prior Yr *Prior year clients Hispanic (actual) 07/13-06/14

163. P1Hispanic Current Yr *Current year clients Hispanic (projected)07/14-06/15

164. P1Hispanic Proposed Yr *Proposed year clients Hispanic (projected)07/15-06/16

ETHNIC BACKGROUND- Asian-American

165. P1Asian-American Prior YrPrior year clients Asian-American (actual)07/13-06/14

166. P1Asian-American Current Yr *Current year clients Asian-American(projected) 07/14-06/15

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167. P1Asian-American Proposed Yr * Proposed year clients Asian-American (projected) 07/15-06/16

ETHNI C BACKGROUND · Nativ e American

168. P1Native American Prior YrPrior year clients Native American (actual)07/13-06/14

169. P1Native American Current Yr * Current year clients Native American (projected) 07/14-06/15

170. P1Native American Proposed Yr * Proposed year clients Native American (projected) 07/15-06/16

ETHNI C BACKGROUN D · Other

171. P1 Other Prior YrPrior year clients Other (actual) 07/13-06/14

172. P1 Other Current YrCurrent year clients Other (projected) 07/14-06/15

173. P1 Other Proposed Yr *Proposed year clients Other (projected) 07/15-06/16

ETHNI C BACKGROUND · Undocumented

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174. P1 Undocumented Prior Yr *Prior year clients Undocumented (actual)07/13-06/14

175. P1 Undocumented Current YrCurrent year clients Undocumented(projected) 07/14-06/15

176. P1 Undocumented Proposed Yr * Proposed year clients Undocumented (projected) 07/15-06/16

LEGAL RESIDENCE DEMOGRAPHICS

FLAGLER

177. P1 Bunnell Prior YrPrior year Bunnell 32110 clients (actual)07/13-06/14

178. P1 Bunnell Current YrCurrent year Bunnell clients (projected) 07/14-06/15

179. P1 Bunnell Proposed YrProposed year Bunnell clients (projected)07/15-06/16

180. P1 Flagler Beach Prior YrPrior year Flagler 32136 clients (actual) 07/13-06/14

181. P1 Flagler Beach Current YrCurrent year Flagler clients (projected) 07/14-06/15

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182. P1 Flagler Beach Proposed YrProposed year Flagler clients (projected)07/15-06/16

183. P1 Marineland Prior YrPrior year Marineland 32086 clients (actual)07/13-06/14

184. P1 Marineland Current YrCurrent year Marineland clients (projected)07/14-06/15

185. P1 Marineland Proposed YrProposed year Marineland clients (projected)07/15-06/16

186. P1 Palm Coast Prior YrPrior year Palm Coast 32135, 32137, 32142,32164 clients (actual) 07/13-06/14

187. P1 Palm Coast Current YrCurrent year Palm Coast clients (projected)07/14-06/15

188. P1 Palm Coast Proposed YrProposed year Palm Coast clients (projected)07/15-06/16

NORTHEAST

189. P1 Daytona Beach Prior YrPrior year Daytona Beach clients (actual)07/13-06/14

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190. P1 Daytona Beach Current YrCurrent year Daytona Beach clients(projected) 07/14-06/15

191. P1 Daytona Beach Proposed YrProposed year Daytona Beach clients(projected) 07/15-06/16

192. P1 Daytona Beach Shores Prior YrPrior year Daytona Beach Shores clients(actual) 07/13-06/14

193. P1 Daytona Beach Shores Current YrCurrent year Daytona Beach Shores clients(projected) 07/14-06/15

194. P1 Daytona Beach Shores Proposed YrProposed year Daytona Beach Shores clients(projected) 07/15-06/16

195. P1 Holly Hill Prior YrPrior year Holly Hill clients (actual) 07/13-06/14

196. P1 Holly Hill Current YrCurrent year Holly Hill clients (projected)07/14-06/15

197. P1 Holly Hill Proposed YrProposed year Holly Hill clients (projected)07/15-06/16

198. P1 Ormond Beach Prior YrPrior year Onnond Beach clients (actual)07/13-06/14

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199. P1 Ormond Beach Current Yr Current year Onnond Beach clients (projected) 07/14-06/15

200. P1 Ormond Beach Proposed YrProposed year Onnond Beach clients(projected) 07/15-06/16

201. P1 PI/Wilbur Prior YrPrior year Ponce Inlet/Wilbur-by-the-Sea clients (actual) 07/13-06/14

202. P1 PI/Wilbur Current YrCurrent year Ponce Inlet/Wilbur-by-the-Sea clients (projected) 07/14-06/15

203. P1 PI/Wilbur Proposed YrProposed year Ponce Inlet/Wilbur-by-the-Sea clients (projected) 07/15-06/16

204. P1 Port Orange Prior YrPrior year Port Orange clients (actual) 07/13-06/14

205. P1 Port Orange Current YrCurrent year Port Orange clients (projected)07/14-06/15

206. P1 Port Orange Proposed YrProposed year Port Orange clients (projected)07/15-06/16

207. P1 South Daytona Prior YrPrior year South Daytona clients (actual)07/13-06/14

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208. P1 South Daytona Current YrCurrent year South Daytona clients (projected)07/14-06/15

209. P1 South Daytona Proposed YrProposed year South Daytona clients(projected) 07/15-06/16

NORTHWEST

210. P1 Barberville Prior YrPrior year Barberville clients (actual) 07/13-06/14

211. P1 Barberville Current YrCurrent year Barberville clients (projected)07/14-06/15

212. P1 Barberville Proposed YrProposed year Barberville clients (projected)07/15-06/16

213. P1 Cassadaga Prior YrPrior year Cassadaga clients (actual) 07/13-06/14

214. P1 Cassadaga Current YrCurrent year Cassadaga clients (projected)07/14-06/15

215. P1 Cassadaga Proposed YrProposed year Cassadaga clients (projected)07/15-06/16

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216. P1 Deland Prior YrPrior year Deland clients (actual) 07/13-06/14

217. P1 Deland Current YrCurrent year Deland clients (projected) 07/14-06/15

218. P1 Deland Proposed YrProposed year Deland clients (projected)07/15-06/16

219. P1 Deleon Springs Prior YrPrior year Deleon Springs clients (actual)07/13-06/14

220. P1 Deleon Springs Current Yr Current year Deleon Springs clients (projected) 07/14-06/15

221. P1 Deleon Springs Proposed YrProposed year Glenwood clients (projected)07/15-06/16

222. P1 Glenwwod Prior YrPrior year Glenwood clients (actual) 07/13-06/14

223. P1 Glenwood Current YrCurrent year Glenwood clients (projected)07/14-06/15

224. P1 Glenwood Proposed YrProposed year Glenwood clients (projected)07/15-06/16

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225. P1 Lake Helen Prior YrPrior year Lake Helen clients (actual) 07/13-06/14

226. P1 Lake Helen Current YrCurrent year Lake Helen clients (projected)07/14-06/15

227. P1 Lake Helen Proposed YrProposed year Lake Helen clients (projected)07/15-06/16

228. P1 Pierson Prior YrPrior year Pierson clients (actual) 07/13-06/14

229. P1 Pierson Current YrCurrent year Pierson clients (projected) 07/14-06/15

230. P1 Pierson Proposed YrProposed year Pierson clients (projected)07/15-06/16

231. P1 Seville Prior YrPrior year Seville clients (actual) 07/13-06/14

232. P1 Seville Current YrCurrent year Seville clients (projected) 07/14-06/15

233. P1 Seville Proposed YrProposed year Seville clients (projected)07/15-06/16

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SOUTHEAST

234. P1 Edgewater Prior YrPrior year Edgewater clients (actual) 07/13-06/14

235. P1 Edgewater Current YrCurrent year Edgewater clients (projected)07/14-06/15

236. P1 Edgewater Proposed YrProposed year Edgewater clients (projected)07/15-06/16

237. P1 New Smyrna Beach Prior YrPrior year New Smyrna Beach clients (actual)07/13-06/14

238. P1 New Smyrna Beach Current Yr Current year New Smyma Beach clients (projected) 07/14-06/15

239. P1 New Smyrna Beach Proposed YrProposed year New Smyma Beach clients(projected) 07/15-06/16

240. P1 Oak Hill Prior YrPrior year Oak Hill clients (actual) 07/13-06/14

241. P1 Oak Hill Current YrCurrent year Oak Hill clients (projected) 07/14-06/15

242. P1 Oak Hill Proposed YrProposed year Oak Hill clients (projected)07/15-06/16

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SOUTHWEST

243. P1 Debary Prior YrPrior year Debary clients (actual) 07/13-06/14

244. P1 Debary Current YrCurrent year Debary clients (projected) 07/14-06/15

245. P1 Debary Proposed YrProposed year Debary clients (projected)07/15-06/16

246. P1 Deltona Prior YrPrior year Deltona clients (actual) 07/13-06/14

247. P1 Deltona Current YrCurrent year Deltona clients (projected) 07/14-06/15

248. P1 Deltona Proposed YrProposed year Deltona clients (projected)07/15-06/16

249. P1 Enterprise Prior YrPrior year Enterprise clients (actual) 07/13-06/14

250. P1 Enterprise Current YrCurrent year Enterprise clients (projected)07/14-06/15

251. P1 Enterprise Proposed YrProposed year Enterprise clients (projected)07/15-06/16

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252. P1 Orange City Prior YrPrior year Orange City clients (actual) 07/13-06/14

253. P1 Orange City Current YrCurrent year Orange City clients (projected)07/14-06/15

254. P1 Orange City Proposed YrProposed year Orange City clients (projected)07/15-06/16

255. P1 Osteen Prior YrPrior year Osteen clients (actual) 07/13-06/14

256. P1 Osteen Current YrCurrent year Osteen clients (projected) 07/14-06/15

257. P1 Osteen Proposed YrProposed year Osteen clients (projected)07/15-06/16

Ill. PROGRAM OUTCOMES

258. INPUTS *What RESOURCES are dedicated to this program?

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259. ACTIVITIES "'What SERVICES are provided?

260. OUTPUTS *What AMOUNTS OF SERVICE are provided?

261. OUTCOME 1 *BENEFIT to program participants

262. Out1 Indicators *How will you measure whether you achieved OUTCOME 1?

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263. Out1 Data Source *Where and how will you get your information for OUTCOME 1?

264. Out1 Prev Yr *Actual previous year 07/13-06/14 for OUTCOME 1

265. Out1 Current Yr *Current year projected 07/14-06/15 for OUTCOME 1

266. Out1 Prop Yr *Proposed year projected 07/15-06/16 for OUTCOME 1

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267. OUTCOME 2 *BENEFIT to program participants

268. Out2 Indicators *How will you measure whether you achieved OUTCOME 2?

269. Out2 Data Source *Where and how will you get your information for OUTCOME 2?

270. Out2 Prev Yr *Actual previous year 07/13-06/14 for OUTCOME 2

42/51

271. Out2 Current Yr *Current year projected 07/14-06/15 for OUTCOME 2

272. Out2 Prop Yr *Proposed year projected 07/15-06/16 for OUTCOME 2

273. OUTCOME 3BENEFIT to program participants

274. Out3 IndicatorsHow will you measure whether you achieved OUTCOME 3?

43/51

275. Out3 Data SourceWhere and how will you get your information for OUTCOME 3?

276. Out3 Prev YrActual previous year 07/13-06/14 for OUTCOME 3

277. Out3 Current YrCurrent year projected 07/14-06/15 for OUTCOME 3

278. Out3 Prop YrProposed year projected 07/15-06/16 for OUTCOME 3

44151


280. Out41ndicatorsHow will you measure whether you achieved OUTCOME 4?



45151




286. Out5 IndicatorsHow will you measure whether you achieved OUTCOME 5?

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291. Measurements *How have you used outcome measurements in the past 12 months to evaluate your programs and what changes did you implement going forward as a result (give specific examples)?

IV. IN-KIND REVENUES

Describe your in-kind revenues (i.e., volunteers, rent, equipment, advertising, etc.). In-kind is defined as anything given to the agency to support the program that the agency would otherwise have to pay for.

292. In-Kind 1 *In-kind revenue 1

293. IK1 Desc *Description of in-kind revenue 1

294. IK1 HoursHours donated for in-kind revenue 1

295. IK1 RateHour1y rate for in-kind revenue 1

296. IK1 Current Yr *Current year (07/14-06/15)

4&'51

297. IK1 Proposed Yr *Proposed year (07/15-06/16)

298. In-Kind 2In-kind revenue 2

299. IK2 DescDescription of in-kind revenue 2


301. IK2 RateHour1y rate for in-kind revenue 2

302. IK2 Current YrCurrent year (07/14-06/15)

303. IK2 Proposed YrProposed year (07/15-06/16)


4S'51



307. IK3 RateHourly rate for in-kind revenue 3




311. IK4DescDescription of in-kind revenue 4


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322. Tot Rev Current Yr *Total In-Kind Revenue Current Year 07/14-06/15

323. Tot Rev Prop Yr *Total In-Kind Revenue Proposed Year 07/15-06/16

324. More Programs *Do you have another program to describe?Mark only one oval.___ Yes

___ No

YOU WILL NEED TO FILL OUT THE PROGRAMS SECTION FOR EACH PROGRAM

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