UNITED WAY OF WESTERN CONNECTICUT
Organization Fact Sheet
Organization Name:
Mailing Address:
City:
State:
Phone #:
Fax #:
Website:
Executive Director:
Zip:
Email:
Phone #:
Contact Person (if different):
Email:
Contact Person Title:
Phone #:
Board President:
Email:
Board President Address:
Phone #:
Organization Mission Statement: Please provide a brief statement of your organization’s mission.
Organizational Affiliations/Licensure/Certifications (please list as applicable):
Signature of Executive Director: ______________________________________Date:__________________________
Signature of Board President: ________________________________________Date:__________________________
1
Program Cover Sheet
Instructions:
Please complete a separate Program Cover Sheet each program for which you are seeking UWWC funding.
Program Name:
If program name has changed, please
write in previous name:
Program Funding $ Amount Requested
for Year One:
New or Existing Program In Agency:
Funded by UWWC Last Year (Yes or No):
Program Purpose/Outcomes:
Health programs focus on the ensuring of mental, physical, and behavioral health of children and adults in our
region.
In considering the short, medium and long term outcomes of the program you are applying for, please check
the long-term outcome listed below that best aligns with your program’s purpose. If you choose more than one
outcome, please indicate with a #1 for the primary outcome:
Health Impact Area Long-Term Outcomes:
_____ People are mentally healthy
_____ Families are well and physically healthy
_____ People are safe and have healthy lifestyles
2
Program Narrative Questions
Instructions:
Please restate and answer all narrative questions listed below for each program for which you are seeking
UWWC funding in the order they are presented in no more than four (4) pages. Font should be a minimum of
size 10 with one inch margins on all sides.
1. Describe the program that you are seeking funding for, please include in your description:
a. the community issue this program seeks to address
b. the target population served by the program
c. best practices used to ensure effectiveness
d. how the program provides services in a different manner or approach than similar services
offered in the community or explain the need for multiple agencies performing similar services
2. List your program outcome measures including results, please include:
a. Program goals and results achieved for each outcome measure in your last fiscal year
b. If a goal was not met, note any influencing factors discovered and program changes made in
order to improve results for the next fiscal year
c. Program goals and results you hope to achieve in the next fiscal year
3. List key program partners and the specific roles they play, please include
a. How your organization uses community resources (board members, volunteers, in-kind
donations, corporate partnerships) to support the program
b. How each partnership contributes to the success of the clients served
4. Describe any significant staffing changes, restructuring or mergers that have occurred to the program
or agency within the past year or may occur within the next year and how it may impact client services.
5. How will UWWC funding contribute to the success of this program and its clients?
3