UWCF Wellness Mid-Year 2023-2024: All Applicants – United Way Central Florida Wellness

1. Application Agency(Required)

Agency Director Email(Required)

3. Contact Phone Number(Required)

4. Agency Primary Contact for this RFP

Including all correspondences, questions, and related documents.

Title

Agency Contact Email(Required)

Agency Contact Phone(Required)

Organization Details

5. Organization Type eligible for funding: 501(c)(3). Please have your IRS Determination Letter ready as it will be needed again in question 20. Continue to question 6.

6. Federal Tax ID or EIN:

7. DUNS Number:

8. Business License Number:

9. Proposed Program Name:(Required)

11. Program & Budget Details

Provide complete and concise responses related to your proposal:

NOTE:

A PROPOSAL MAY BE SUBMITTED FOR BOTH CATEGORIES. PROVIDE A SEPARATE APPLICATION FOR EACH AND/OR
RFP SUBMISSION FOR ONE-YEAR PROGRAM/SERVICE PROPOSAL ALIGNED WITH EITHER CATEGORY

Each “Text Box” response is limited to a maximum of 300 words.

b. Funding Amount Requested:

c. Amount of Total Program Budget:

e. Briefly tell us about your Agency’s overall background and history, and the different programs you provide.

f. Please provide a 25-word summary description of the program.

g. Describe your organization’s experience and strengths relevant to your proposed program.

h. Describe the problem being addressed by your proposal, documenting the need for services with current local data/statistics (cite your reference).

i. Describe the program (including an explanation of improved health outcomes or resulting outcome) for which funding is sought.

j. How long will the typical client be engaged in the program?

k. List how, when, and where will the services be accessed by the client.

Please list the licenses/ permits required for operation. Include anticipated staffing addition/changes or movement of current staff.

m. How will the program be promoted (how will you reach the target audience as defined by the UWCF Community Wellness Initiative)? List any community outreach to be offered along with marketing strategies.

n. How will you target uninsured, low-income Polk County Residents (individuals and/or families)?

o. Describe the referral process to be used to generate program participant referrals to the program (include names of agencies and/or programs in your local network which will generate referrals to this program).

p. Describe how you identify behavioral health OR prevention / early intervention disparities through your current work.

q. Describe any collaborative partnerships that directly impact the proposed program; will bring extra value to the clients served; and/or eliminate duplication of services and maximize resources {provide any Letters of Commitment, Letters of Support and/or MOU(s)}.

List the EBP and a web link that documents and describes the EBP.

s. Provide the SMART Goals & Objectives for the proposed program.

Click the following link for a guide on SMART objectives: How to Write S.M.A.R.T. Goals & Objectives Smartsheet

t. Describe the data to be collected to document the success of the proposed program; including evaluation timeframe, how it will be collected; and who is responsible for collecting it and reporting to UWCF.

u. Provide the benchmarks and standards that are applicable to the proposed program. Be sure to include the evaluation timeframe.

v. Provide a timeline for the implementation plan of the proposed project as an Attachment.

Drop files here or

Max. file size: 300 MB.

Program Service Details

13. a. Total number of people to be served each year:

14. Number of people to be enrolled or are currently enrolled if an existing program.

Required Documents (17 - 20):

17. Proposed Program Budget

Drop files here or

Max. file size: 300 MB.

18. Proposed Personnel Detail Budget

Drop files here or

Max. file size: 300 MB.

19. Proposed Fee for Service Schedule

Drop files here or

Max. file size: 300 MB.

20. 501(c)(3) Determination Letter

Drop files here or

Max. file size: 300 MB.

Required Financials (21 - 26):

21. Financial Statement (Signed by CFO or Board Treasurer)(Required)

Drop files here or

Max. file size: 300 MB.

22. Income Statement & Statement of Cash Flows(Required)

Drop files here or

Max. file size: 300 MB, Max. files: 2.

23. Certificate of Commercial Liability Insurance(Required)

Drop files here or

Max. file size: 300 MB.

24. Form 990 (Most recent)(Required)

Drop files here or

Max. file size: 300 MB.

25. Audit Report (Most recent)(Required)

Drop files here or

Max. file size: 300 MB.

26. W-9(Required)

Drop files here or

Max. file size: 300 MB.

Additional Documentation & Questions

27. Expansion of program/services: Provide successful data of current program to expand. Additionally, provide data analysis of current program to expand under client eligibility criteria under UWCF Community Wellness (Ref., Polk County resident, FPL less than or equal to 200% and no health coverage).

Drop files here or

Max. file size: 300 MB, Max. files: 2.

28. Continuation of a program that will end due to complete loss of funding: Provide the success of program - must be empirically demonstrated. Please also provide an explanation of what the funding was and why it was lost.

Drop files here or

Max. file size: 300 MB.

30. A significant partnership with another agency (1): Attach signed Letters of Commitment, Letters of Support and/or MOU from that agency’s Director or other authorized representative.

Drop files here or

Max. file size: 300 MB, Max. files: 3.

31. A significant partnership with another agency (2): Attach signed Letters of Commitment, Letters of Support and/or MOU from that agency’s Director or other authorized representative.

Drop files here or

Max. file size: 300 MB, Max. files: 3.

Authorization & Submission

Authorized physical signature of applicant/lead organization

To the best of my knowledge and belief, all information in this application is true and correct. The document has been duly authorized by the governing body of the applicant who will comply with all contractual obligations if the applicant is awarded funding.

Signature

Date

Community Wellness Application (Mid-Year 2023 – 2024)

4. Agency Primary Contact for this RFP

Organization Details

11. Program & Budget Details

Program Service Details

Required Documents (17 - 20):

Required Financials (21 - 26):

Additional Documentation & Questions

Authorization & Submission