Oshkosh Funding Consortium Grant Application 2015
Application COVER SHEET
Deadline: Friday, February 27, 2015 at 3:30PM
Please attach one organization cover sheet with each program application submitted.
Application must be completed in full to be considered
Submit 1 signed original & 1 electronic application to Darlene Brandt - [email protected]
(electronic version must not exceed 10MB)
City Hall, 215 Church Street, Community Development Office Rm. 201 - orPO Box 1130• Oshkosh, WI 54903-1130
Attachments, brochures or other materials may be included in your original packet ONLY.
APPLICANT INFORMATION
Organization:
Mailing Address:
Phone:
Fax:
Web Address:
Federal Tax Identification Number:
Legal Status of Organization: (Select One)
___ Private, Non-profit - 501(c) 3 ____ Private, For-profit
Director/CEO’s Name:
Director/CEO’s E-Mail:
___ Public Agency
Director/CEO’s Phone:
Director/CEO’s Signature:
X____________________________________
I have read and agree with the information within this application.
Provide mission statement/purpose:
Organization’s total operating budget:
List the names of all the programs and amount of funding requested below:
Names of Programs 1
Amount of Funds Requested
1.
2.
3.
Total Amount of Funding Requested
1
____ Other
Attach a Program Narrative - Form 1 for each program listed in the table above.
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2015 PROGRAM NARRATIVE – form 1
(Please submit one application per program)
Name of program for which you are requesting funding:
Is this a new program? ___Yes ___No
Amount of funding you are requesting:
Have you requested money for this program in the past? ___Yes ___No
Are you proposing to increase your level of services with this grant?
___Yes ___ No. If yes, please
state why, including but not limited to expanded services you plan to offer, increased need, growth in
number of clients to be served, increased geographic service area, etc. (maximum of 250 words ):
PROGRAM NARRATIVE: This section is designed to help you identify which of the following Oshkosh
Funding Consortium impact areas BEST DESCRIBES your program. Select just one: Income, Education or Health.
 INCOME: Helping
Families Become
Financially Stable
and Independent
(Select all that apply)
 Basic Needs
 Employment
 Housing
 Childcare
 Financial
Literacy/Repairing
Credit & Reducing
Debt
 Financial
Assistance
 Legal Assistance
 Adult/Family
Literacy
 Job Retention/
Unemployment
Prevention
 Self-Sufficiency
Attainment
 Advocacy
 Other (please
explain within
column space
below)
 EDUCATION: Helping
Children and Youth
Achieve Their
Potential (Select all
that apply)
 Early Learning
 School
Readiness
 Childhood
Growth &
Development
 Third Grade
Reading
Proficiency
 Youth Growth &
Development
 After School
Programing
 Mentoring
 Career
Education
 Student
Engagement
 On time High
School
Graduation
 Higher
Education,
Work & Life
Goals
 Truancy
Prevention
 Parent
Engagement
 Strengthening
Families
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
HEALTH:
Improving People’s Health (Select all that apply)
 Health Care Access
 Mental/Emotional Health
 Dental Health
 Addiction Prevention
 Addiction Treatment
 Physical Activity & Nutrition
 Injury Prevention
 Parenting Skills
 Abuse/Neglect Prevention
 Health & Wellness
 Healthy Relationships
 Safety/Well-being
 Advocacy
 Other (please explain within column space below)
 Advocacy
 Other (please
explain within
column space
below)
Describe why the program for which you are requesting funds fits in one impact area of Education, Income or
Health (maximum of 250 words):
PROGRAM DESCRIPTION
Complete the following with a maximum of 500 words each.
Provide a specific description of the program for which you are requesting funds.
What activities will you use to accomplish your program outcomes (project plan) ?
What best practices or evidence-based activities have you used to accomplish your program outcomes.
(Please site the evidence-based research you have identified.)
PROGRAM DEMOGRAPHIC
(Please complete and attach Program Participant Summary Sheet – Form 4.)
(For Community Development Block Grant (CDBG) applications only: What percent of program
participants are City of Oshkosh residents? _____%
PROGRAM ASSESSMENT
Answer the questions below with a maximum of 500 words each.
What are the specific local needs/problems/gaps (in service) your program will address?
How did you determine the needs for this program? (state specific research or studies)
Does this program address the root cause or the symptom of the issue? (Is the program providing a long
term solution or a short term fix?)
PROGRAM OUTCOMES - State proposed outcomes for CURRENT YEAR.
Select and submit on no more than three outcomes.
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Outcome 1: (example: Teens are knowledgeable of prenatal nutrition and health guidelines.)
Outcome Target (s): (example: Number and percent of program participants able to identify food items that
are good sources of major dietary requirements.)
Data Source(s): (example: participants, client tests, staff observations, etc.)
Data Collection Method (s): (example: Self-administered survey after second week in the program.)
How has this outcome been changed or redesigned based on last year’s outcome evaluation?
Outcome 2: (example: Teens follow proper nutrition and health guidelines)
Outcome Target (s): (example: Number and percent of participants within proper ranges for prenatal weight
gain. Number and percent of participants that do not smoke. Number and percent of participants that take
prenatal vitamin each day.)
Data Source(s): (example: school scales, participants, teachers, client tests, staff observations, etc.)
Data Collection Method (s): (example: Weekly weigh-ins, self-report on daily checklist, observation reported
on weekly record, “Healthy Baby” checklist for recording daily food intake, pre or post-test or observation,
etc.)
How has this outcome been changed or redesigned based on last year’s outcome evaluation?
Outcome 3: (example: Teens deliver healthy babies.)
Outcome Target (s): (example: Number and percent of newborns weighing 5.5 pounds or above and scoring
7 or above on Apgar scale.)
Data Source(s): (example: Hospital records)
Data Collection Method (s): (example: Contact hospital for birth records.)
How has this outcome been changed or redesigned based on last year’s outcome evaluation?
PROGRAM ANALYSIS Please answer the questions below with a maximum of 250 words per response.
How do the program’s outcomes coincide with the organization’s mission and values?
Are there other organizations that provide similar programs/services for Greater Oshkosh? ___Yes ___No
If yes, who?
How is your program unique?
Why is your organization best suited to provide this program?
Do you have a waiting list? ___Yes ____ No. If yes, to what degree? #_______ Length of wait? _________
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What is the number of people you have been unable to serve in the past year? #______ Explain why.
PROGRAM COLLABORATIONS Please use the definition of collaboration provided below to complete this
section.
Collaboration Defined: A mutually beneficial and well-defined relationship entered into by two or more
organizations to achieve common goals. The relationship must include a COMMITMENT OR COMPONENT of:
 Shared Goals
 A jointly developed structure and shared responsibility
 Mutual authority and accountability for success
 Sharing of resources, risk and reward.
Does the proposed program involve collaboration with other organizations?
Yes, ___
No, ___
LIST collaborative partners with a brief explanation of your relationship.
Please provide an example of how working collaboratively with other organization(s) helps your program
achieve greater impact.
PROGRAM FUNDING Answer the following questions about funding. Keep in mind the Oshkosh Funding
Consortium funding is not to be considered an entitlement.
If your organization receives partial funding for the proposed program, would you be able to raise the
remaining funds to operate the program? If yes describe how:
If not, how would you adjust your program?
Describe the organization’s long-term funding plan:
2014 PROGRAM SUCCESS STORY
Please provide one story per program that exemplifies its success. Stories should be no longer than three
paragraphs and should relate to residents of the Greater Oshkosh Area.
 Please identify the outcome(s) you want communicated to the public including, data with number of
clients and the percent that achieved success.
 Include information about why Oshkosh Funding Consortium funding is important to your
organization’s ability to achieve successful outcomes.
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