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, Inc
Funding Application for Fiscal Year 2015-2016
*Required
1. Agency Name *
2. DBA
Agency 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-letter
Abbreviation
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 Service
Check 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 services
Check 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
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41. Governance
If 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 Details
If 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
___ At least 50% of the appointed board
___ At least 75% of the appointed board
IV. AGENCY FUNDING SUMMARY
45. Matching Funds
11
Does your agency receive matching funds?
Mark only one oval.
___ Yes
___ No
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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%
___
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 servicessliding 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
Greater than $15,000
56. Financial Services *
Mark only one oval.
___ 0
$1-$2,500
___
___ $2,501-$5,000
___
___
$5,001-$15,000
Greater than $15,000
57. Office Real Estate •
Mark only one oval.
___ 0
$1-$2,500
___
___ $2,501-$5,000
___
___
$5,001-$15,000
Greater than $15,000
1Q'51
58. Volunteers *
Mark only one oval.
___ 0
$1-$2,500
___
___ $2,501-$5,000
___
___
$5,001-$15,000
Greater than $15,000
59. Other *
Mark only one oval.
___ 0
$1-$2,500
___
___ $2,501-$5,000
___
___
$5,001-$15,000
Greater than $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 Details
If 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 significant
program impact
___ Significant- greater than 15% of operating/program, unable to operate program at
prior 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 to
provide 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-EVALUATION
Relationship with United Way
70. Agency Agreement *
The board understands and approves the United Way Agency Agreement
Mark only one oval.
___ Yes
___ No
71. Fundraising Policies *
The agency is knowledgeable of and follows United Way fundraising policies
Mark only one oval.
___ Yes
___ No
72. Internal Fundraising Campaign *
The agency conducts an internal United Way fundraising campaign among its employees
Mark only one oval.
___ Yes
___ No
73. PaceSetter Agency
If 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 Training
Mark only one oval.
___ Yes
___ No
79. Grant Workshop *
Staff representative(s) from the agency attended the Grand Workshop for the Funding
Application
Mark only one oval.
___ Yes
___ No
80. Self Evaluation Comments
Please 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 this
Application
82. P1 *
Program One Name
83. P1 Amount *
Amount Requested
84. P2
Program Two Name
85. P2 Amount
Amount Requested
86. P3
Program Three Name
87. P3 Amount
Amount Requested
88. P4
Program Four Name
89. P4 Amount
Amount Requested
90. P5
Program Five Name
91. P5 Amount
Amount Requested
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92. P6
Program Six Name
93. P6 Amount
Amount Requested
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 Source
If matching funds are received, indicate the funding source.
102. P1 Match Ratio
Identify 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 cap
of $50,000 (i.e. $50,000 brings in a maximum of $200,000).
103. P1 Grant *
Was a grant requested last year?
Mark only one oval.
___ Yes
___ No
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104. P1 Increase Request *
Was a funding increase requested?
Mark only one oval.
___ Yes
___ No
105. P1 Client Fees *
Were there client fees? Mark only one oval.
___ Yes
___ No
106. P1 Clients Served *
Number of clients served (Unduplicated
Services) (2014-2015 Projection)
107. P1 Cost/Client *
Cost/client (in$)(# 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
2Q'51
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 Comments
If yes, please explain the change and impact on the program.
115. Prog 1 New Program
If 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 Age
If 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.
2Q'51
118. Prog 1 Fees *
Are client fees charged for this program?
Mark only one oval.
___ Yes
___ No
119. Prog 1 Fee Range
If yes, what is the range of fees, and how are these fees determined?
120. Prog 1 Fee Waiver
If 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) 07/1306/14
124. P1 0-5 Current Yr *
Current year clients aged 0-5 (projected)
07/14-06/15
125. P1 0-5 Proposed Yr
Proposed 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) 07/1306/14
127. P1 6-10 Current Yr *
Current year clients aged 6-10 (projected)
07/14-06/15
128. P1 6-10 Proposed Yr *
Proposed year clients aged 6-10 (projected)
07/15-06/16
AGE GROUP 11-17
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137. P1 30-54 Proposed Yr *
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 Yr
Proposed 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) 07/1306/14
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) 07/1306/14
136. P1 30-54 Current Yr *
Current year clients aged 30-54 (projected)
07/14-06/15
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137. P1 30-54 Proposed Yr *
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) 07/1306/14
139. P1 55-64 Current Yr *
Current year clients aged 55-64 (projected)
07/14-06/15
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
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144. P1Undocumented Prior Yr
Prior year clients age undocumented (actual)
07/13-06/14
145. P1 Undocumented Current Yr
Current year clients age undocumented
(projected) 07/14-06/15
146. P1 Undocumented Proposed Yr
Proposed 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) 07/1306/15
149. P1 Male Proposed Yr
Proposed year clients Male (projected) 07/1506/16
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) 07/1406/15
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152. P1 Female Proposed Yr
Proposed year clients Female (projected)
07/15-06/16
GENDER GROUP -Undocumented
153. P1 Undocumented Prior Yr
Prior 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 Yr
Proposed year clients Undocumented
(projected) 07/15-06/16
ETHNIC 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) 07/1306/14
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 Yr
Prior 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
ETHNIC BACKGROUND ·Native American
168. P1Native American Prior Yr
Prior 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
ETHNIC BACKGROUND·Other
171. P1 Other Prior Yr
Prior year clients Other (actual) 07/13-06/14
172. P1 Other Current Yr
Current year clients Other (projected) 07/14-
06/15
173. P1 Other Proposed Yr *
Proposed year clients Other (projected) 07/15-
06/16
ETHNIC BACKGROUND·Undocumented
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174. P1 Undocumented Prior Yr *
Prior year clients Undocumented (actual)
07/13-06/14
175. P1 Undocumented Current Yr
Current 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 Yr
Prior year Bunnell 32110 clients (actual)
07/13-06/14
178. P1 Bunnell Current Yr
Current year Bunnell clients (projected) 07/14-
06/15
179. P1 Bunnell Proposed Yr
Proposed year Bunnell clients (projected)
07/15-06/16
180. P1 Flagler Beach Prior Yr
Prior year Flagler 32136 clients (actual) 07/1306/14
181. P1 Flagler Beach Current Yr
Current year Flagler clients (projected) 07/14-
06/15
2W51
182. P1 Flagler Beach Proposed Yr
Proposed year Flagler clients (projected)
07/15-06/16
183. P1 Marineland Prior Yr
Prior year Marineland 32086 clients (actual)
07/13-06/14
184. P1 Marineland Current Yr
Current year Marineland clients (projected)
07/14-06/15
185. P1 Marineland Proposed Yr
Proposed year Marineland clients (projected)
07/15-06/16
186. P1 Palm Coast Prior Yr
Prior year Palm Coast 32135, 32137, 32142,
32164 clients (actual) 07/13-06/14
187. P1 Palm Coast Current Yr
Current year Palm Coast clients (projected)
07/14-06/15
188. P1 Palm Coast Proposed Yr
Proposed year Palm Coast clients (projected)
07/15-06/16
NORTHEAST
189. P1 Daytona Beach Prior Yr
Prior year Daytona Beach clients (actual)
07/13-06/14
3CY51
190. P1 Daytona Beach Current Yr
Current year Daytona Beach clients
(projected) 07/14-06/15
191. P1 Daytona Beach Proposed Yr
Proposed year Daytona Beach clients
(projected) 07/15-06/16
192. P1 Daytona Beach Shores Prior Yr
Prior year Daytona Beach Shores clients
(actual) 07/13-06/14
193. P1 Daytona Beach Shores Current Yr
Current year Daytona Beach Shores clients
(projected) 07/14-06/15
194. P1 Daytona Beach Shores Proposed Yr
Proposed year Daytona Beach Shores clients
(projected) 07/15-06/16
195. P1 Holly Hill Prior Yr
Prior year Holly Hill clients (actual) 07/13-
06/14
196. P1 Holly Hill Current Yr
Current year Holly Hill clients (projected)
07/14-06/15
197. P1 Holly Hill Proposed Yr
Proposed year Holly Hill clients (projected)
07/15-06/16
198. P1 Ormond Beach Prior Yr
Prior 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 Yr
Proposed year Onnond Beach clients
(projected) 07/15-06/16
201. P1 PI/Wilbur Prior Yr
Prior year Ponce Inlet/Wilbur-by-the-Sea
clients (actual) 07/13-06/14
202. P1 PI/Wilbur Current Yr
Current year Ponce Inlet/Wilbur-by-the-Sea
clients (projected) 07/14-06/15
203. P1 PI/Wilbur Proposed Yr
Proposed year Ponce Inlet/Wilbur-by-the-Sea
clients (projected) 07/15-06/16
204. P1 Port Orange Prior Yr
Prior year Port Orange clients (actual) 07/1306/14
205. P1 Port Orange Current Yr
Current year Port Orange clients (projected)
07/14-06/15
206. P1 Port Orange Proposed Yr
Proposed year Port Orange clients (projected)
07/15-06/16
207. P1 South Daytona Prior Yr
Prior year South Daytona clients (actual)
07/13-06/14
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208. P1 South Daytona Current Yr
Current year South Daytona clients (projected)
07/14-06/15
209. P1 South Daytona Proposed Yr
Proposed year South Daytona clients
(projected) 07/15-06/16
NORTHWEST
210. P1 Barberville Prior Yr
Prior year Barberville clients (actual) 07/1306/14
211. P1 Barberville Current Yr
Current year Barberville clients (projected)
07/14-06/15
212. P1 Barberville Proposed Yr
Proposed year Barberville clients (projected)
07/15-06/16
213. P1 Cassadaga Prior Yr
Prior year Cassadaga clients (actual) 07/1306/14
214. P1 Cassadaga Current Yr
Current year Cassadaga clients (projected)
07/14-06/15
215. P1 Cassadaga Proposed Yr
Proposed year Cassadaga clients (projected)
07/15-06/16
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216. P1 Deland Prior Yr
Prior year Deland clients (actual) 07/13-06/14
217. P1 Deland Current Yr
Current year Deland clients (projected) 07/1406/15
218. P1 Deland Proposed Yr
Proposed year Deland clients (projected)
07/15-06/16
219. P1 Deleon Springs Prior Yr
Prior 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 Yr
Proposed year Glenwood clients (projected)
07/15-06/16
222. P1 Glenwwod Prior Yr
Prior year Glenwood clients (actual) 07/1306/14
223. P1 Glenwood Current Yr
Current year Glenwood clients (projected)
07/14-06/15
224. P1 Glenwood Proposed Yr
Proposed year Glenwood clients (projected)
07/15-06/16
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225. P1 Lake Helen Prior Yr
Prior year Lake Helen clients (actual) 07/1306/14
226. P1 Lake Helen Current Yr
Current year Lake Helen clients (projected)
07/14-06/15
227. P1 Lake Helen Proposed Yr
Proposed year Lake Helen clients (projected)
07/15-06/16
228. P1 Pierson Prior Yr
Prior year Pierson clients (actual) 07/13-06/14
229. P1 Pierson Current Yr
Current year Pierson clients (projected) 07/1406/15
230. P1 Pierson Proposed Yr
Proposed year Pierson clients (projected)
07/15-06/16
231. P1 Seville Prior Yr
Prior year Seville clients (actual) 07/13-06/14
232. P1 Seville Current Yr
Current year Seville clients (projected) 07/1406/15
233. P1 Seville Proposed Yr
Proposed year Seville clients (projected)
07/15-06/16
36151
SOUTHEAST
234. P1 Edgewater Prior Yr
Prior year Edgewater clients (actual) 07/1306/14
235. P1 Edgewater Current Yr
Current year Edgewater clients (projected)
07/14-06/15
236. P1 Edgewater Proposed Yr
Proposed year Edgewater clients (projected)
07/15-06/16
237. P1 New Smyrna Beach Prior Yr
Prior 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 Yr
Proposed year New Smyma Beach clients
(projected) 07/15-06/16
240. P1 Oak Hill Prior Yr
Prior year Oak Hill clients (actual) 07/13-06/14
241. P1 Oak Hill Current Yr
Current year Oak Hill clients (projected) 07/1406/15
242. P1 Oak Hill Proposed Yr
Proposed year Oak Hill clients (projected)
07/15-06/16
36151
SOUTHWEST
243. P1 Debary Prior Yr
Prior year Debary clients (actual) 07/13-06/14
244. P1 Debary Current Yr
Current year Debary clients (projected) 07/1406/15
245. P1 Debary Proposed Yr
Proposed year Debary clients (projected)
07/15-06/16
246. P1 Deltona Prior Yr
Prior year Deltona clients (actual) 07/13-06/14
247. P1 Deltona Current Yr
Current year Deltona clients (projected) 07/1406/15
248. P1 Deltona Proposed Yr
Proposed year Deltona clients (projected)
07/15-06/16
249. P1 Enterprise Prior Yr
Prior year Enterprise clients (actual) 07/1306/14
250. P1 Enterprise Current Yr
Current year Enterprise clients (projected)
07/14-06/15
251. P1 Enterprise Proposed Yr
Proposed year Enterprise clients (projected)
07/15-06/16
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252. P1 Orange City Prior Yr
Prior year Orange City clients (actual) 07/13-
06/14
253. P1 Orange City Current Yr
Current year Orange City clients (projected)
07/14-06/15
254. P1 Orange City Proposed Yr
Proposed year Orange City clients (projected)
07/15-06/16
255. P1 Osteen Prior Yr
Prior year Osteen clients (actual) 07/13-06/14
256. P1 Osteen Current Yr
Current year Osteen clients (projected) 07/14-
06/15
257. P1 Osteen Proposed Yr
Proposed 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
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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 3
BENEFIT to program participants
274. Out3 Indicators
How will you measure whether you achieved OUTCOME 3?
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275. Out3 Data Source
Where and how will you get your information for OUTCOME 3?
276. Out3 Prev Yr
Actual previous year 07/13-06/14 for OUTCOME 3
277. Out3 Current Yr
Current year projected 07/14-06/15 for OUTCOME 3
278. Out3 Prop Yr
Proposed year projected 07/15-06/16 for OUTCOME 3
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279. OUTCOME 4
BENEFIT to program participants
280. Out41ndicators
How will you measure whether you achieved OUTCOME 4?
281. Out4 Data Source
Where and how will you get your information for OUTCOME 4?
282. Out4 Prev Yr
Actual previous year 07/13-06/14 for OUTCOME 4
44151
283. Out4 Current Yr
Current year projected 07/14-06/15 for OUTCOME 4
284. Out4 Prop Yr
Proposed year projected 07/15-06/16 for OUTCOME 4
285. OUTCOME 5
BENEFIT to program participants
286. Out5 Indicators
How will you measure whether you achieved OUTCOME 5?
45151
287. Out5 Data Source
Where and how will you get your information for OUTCOME 5?
288. Out5 Prev Yr
Actual previous year 07/13-06/14 for OUTCOME 5
289. Out5 Current Yr
Current year projected 07/14-06/15 for OUTCOME 5
290. Out5 Prop Yr
Proposed year projected 07/15-06/16 for OUTCOME 5
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 Hours
Hours donated for in-kind revenue 1
295. IK1 Rate
Hour1y rate for in-kind revenue 1
296. IK1 Current Yr *
Current year (07/14-06/15)
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297. IK1 Proposed Yr *
Proposed year (07/15-06/16)
298. In-Kind 2
In-kind revenue 2
299. IK2 Desc
Description of in-kind revenue 2
300. IK2 Hours
Hours donated for in-kind revenue 2
301. IK2 Rate
Hour1y rate for in-kind revenue 2
302. IK2 Current Yr
Current year (07/14-06/15)
303. IK2 Proposed Yr
Proposed year (07/15-06/16)
304. In-Kind 3
In-kind revenue 3
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305. IK3 Desc
Description of in-kind revenue 3
306. IK3 Hours
Hours donated for in-kind revenue 3
307. IK3 Rate
Hourly rate for in-kind revenue 3
308. IK3 Current Yr
Current year (07/14-06/15)
309. IK3 Proposed Yr
Proposed year (07/15-06/16)
310. In-Kind 4
In-kind revenue 4
311. IK4Desc
Description of in-kind revenue 4
312. IK4 Hours
Hours donated for in-kind revenue 4
4S'51
313. IK4 Rate
Hourly rate for in-kind revenue 4
314. IK4 Current Yr
Current year (07/14-06/15)
315. IK4 Proposed Yr
Proposed year (07/15-06/16)
316. In-Kind 5
In-kind revenue 5
317. IK5 Desc
Description of in-kind revenue 5
318. IK5 Hours
Hours donated for in-kind revenue 5
319. IK5 Rate
Hourly rate for in-kind revenue 5
320. IK5 Current Yr
Current year (07/14-06/15)
321. IK5 Proposed Yr
Proposed year (07/15-06/16)
322. Tot Rev Current Yr *
Total In-Kind Revenue Current Year 07/1406/15
323. Tot Rev Prop Yr *
Total In-Kind Revenue Proposed Year 07/1506/16
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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