2021-22 Social Innovation Funding Application Step 1 of 4 25% Agency InformationProgram and/or Project Name* Is your program part of a nonprofit organization?* Yes No What type of nonprofit is your program a part of?*501(c)3City, County, or StateSchool or school related afterschoolReligious OrganizationName of Nonprofit Organization* Nonprofit Executive Director* Name of Program Contact* Mailing Address* City / State / Zip* Phone NumberEmail Address* Is your program or project under 2 years old?* If your program has not yet launched, please provide your expected start date.* Which category does your program address? Select all that apply* Health Education Financial Stability What is your fiscal year?* Is your program covered by your agency insurance?* Program/Project OverviewDescribe the mission of your organization.*Describe the program or project you would like to receive funding for.*Which county in our area will your program support?* Select All Washington Carter Johnson Southern Sullivan How many people do you hope to directly impact from this program or project?* Briefly explain how your program would be staffed (paid employees, volunteers, etc.)*Please provide a budget for the program. If the budget exceeds the grant amount of $10,000, please denote what part of the budget this grant would be applied to.*Explain why you believe there is a community need for this program.*Describe how you hope your program brings long-term or short-term impact on the community.*What metrics will you use to evaluate the success of the program?* Additional InformationDescribe the program in 1500 characters or less*Describe the target population to be addressed (age, sex, socio-economic level, special needs, etc.)*Do you have other sources of funding in place for this program? If so, what are they?*How do you market/communicate your agency's program(s) to the community?*Do you coordinate with other agencies/organizations in the community? If so, how?* Consent* I agree to the Statement of AgreementAs a funded agency of the United Way of East TN Highlands we accept the following principles and conditions: A. BOTH UNITED WAY OF EAST TN HIGHLANDS AND THE PARTNER AGENCY AGREE 1. To maintain an active, rotating volunteer structure which assumes and fulfills the responsibility of managing its affairs within the scope and spirit of respective by-laws and this agreement. 2. Offer opportunity for participation in programs, services, policy designation and staff employment to persons regardless of race, religion, age, sex, national origin, sexual orientation, and disability. 3. To strive to increase the public's understanding and appreciation of and participation in human services programs. 4. To consult and work together on matters of common interest in an effort to achieve the best interest of the community as a whole. B. THE AGENCY AGREES 1. To maintain a positive and supportive relationship with United Way and the United Way Staff in all communications and throughout the community. 2. To support and assist in the United Way of East TN Highlands annual fundraising campaign. 3. To engage in an effective year-round public relations program in which the objectives, services and accomplishments of the Agency, and the United Way of East TN Highlands support of such services, are adequately publicized. 4. To have a complete audit of its financial affairs made each year and to furnish the most recent copy to the United Way of East TN Highlands with their application for funding (audit review for agencies with less than $100,000.00 in gross receipts). 5. To provide semi-annual financial statements to United Way of East TN Highlands (e.g. Profit & Loss and Balance Sheets). Failure to provide semi-annual financial statements in a timely manner could result in loss of funding for your agency program. 6. To provide a semi-annual report to the United Way of East TN Highlands indicating the number of clients served and the impact results of the program being funded. (format to be provided). Failure to provide semi-annual reports in a timely manner could result in loss of funding for your agency program. 7. To carry out the programs of the agency in such a manner as will best meet the needs of the community and will be consistent with standards of service, efficiency and economy. 8. After being given full consideration and hearing, to accept the apportionment of funds made to it by the Allocations Committee and approved by the United Way of East TN Highlands Board of Directors. 9. To submit a minimum of one Week of Caring volunteer project request by the end of April to be completed in the month of June (preferably during the Week of Caring). 10. The agency should also be represented by staff executive leadership at the following events: All United Way Impact Awards (April) All Quarterly Executive Director Meetings If service area covers Carter County, Golf Tournament August 13, 2021 C. THE UNITED WAY OF EAST TN HIGHLANDS AGREES 1. To provide resources to strengthen partner agencies. 2. To respect the agency's prerogative of determining its own policies and programs within the community. 3. To use its best efforts to achieve the campaign objectives and fund Agency Programs that are making significant impact in the categories of Health, Education, and Financial Stability. 4. To act as responsible stewards of funds publicly contributed to the United Way by fully informing contributors of the allocations and use of the funds. 5. To submit all its financial records for an audit by an independent public accountant. Electronic Signature of Agency Executive Director / CEO or Program/Project Contact (Please type your name below)* Today's Date* MM slash DD slash YYYY Δ
