Organization Information
Client Demographic Information
Contact Information
Executive Director/President/CEO
Primary Contact for Request
Request Information
Goals and Objectives
|
Bruening Foundation Application |
Organization Information | ||
| Organization Name | ||
| Address | ||
| City | ||
| State | ||
| <Select One> | ||
| Zip Code | ||
| Phone | ||
| Website | ||
| Federal Tax ID | ||
| 000 | ||
| Tax Status | ||
| <Select One> | ||
| Organization Background | ||
| In a paragraph, give the mission and a brief history of the organization, including the year it was founded and how it has evolved since it was founded. (150 word limit) | ||
| Staff Information | ||
| In a brief paragraph, describe your staff, including how many staff members you have in each of these categories: full-time, part-time, interns and volunteers. (45 Word Limit) | ||
| Programs and Services | ||
| Without repeating the information in the Organization Background field above, list the organization's programs. Include a brief description and the numbers of clients served in each program during the last fiscal year. For example, XYZ operates the following programs (with 2010 service figures): child care -- full day program for infants and toddlers 6 weeks to 5 years (40 served); senior lunch program -- congregate meals and activities 5 days a week (120 served); and community garden -- planted and maintained by seniors and teens (50 participated). (150 word limit) | ||
Client Demographic Information | ||
| The information in this section should be reflective of the total clients served by the organization. First enter the total number of clients served and then enter the percentage of clients served in each category. Enter whole numbers only and do not enter a % sign with the number. If you do not have a percentage to enter for the category, enter 0. | ||
| Fiscal Year for Data (start date) | ||
| Provide the start date for the fiscal year for the client data provided below | ||
| Fiscal Year for Data (end date) | ||
| Provide the end date for the fiscal year | ||
| Total number of clients served | ||
| List the total number of clients served by the organization during the fiscal year entered above. Enter a whole number, not a range. | ||
| Percentage African American | ||
| Percentage Asian | ||
| Percentage Caucasian | ||
| Percentage Hispanic/Latino | ||
| Percentage Native American | ||
| Percentage categorized as other | ||
| Total | ||
| Press the calculator icon to ensure that the total is 100% | ||
| 0.00% | ||
| Percentage female | ||
| Whole number only, no percentage | ||
| Percentage male | ||
| Whole number only, no percentage | ||
| Percentage of low income clients served | ||
| If you collect income information about your clients, give the percentage of clients served that are below 150% of federal poverty level based on the Health and Human Services Poverty Guidelines. Whole number only, no percentage. If your organization does not collect this information, enter N/A here. | ||
| Description of Clients Served | ||
| Provide any other detailed information not reflected in the numbers above about the population you serve. (100 word limit) | ||
| Current environment | ||
| If appropriate, provide context or any pertinent information about changes in your organization's circumstances or client needs that supplement our understanding of why you are making this request. (50 word limit) | ||
Contact Information | ||
Executive Director/President/CEO | ||
| Prefix | ||
| Example: Mr., Ms. | ||
| First Name | ||
| Last Name | ||
| Title | ||
| Office Phone | ||
| Extension | ||
Primary Contact for Request | ||
| Same as above | ||
| Prefix | ||
| First Name | ||
| Last Name | ||
| Title | ||
| Office Phone | ||
| Extension | ||
Request Information | ||
| Request Amount | ||
| Whole numbers only | ||
| Type of Support | ||
| Project/Program Title | ||
| Please briefly describe your project/program in 10 words or less. You will have an opportunity to fully describe your project below. Examples: to provide counseling services to teens; to increase capacity at the health clinic; for a job training program for low-skilled individuals | ||
| Project Start Date | ||
| Project End Date | ||
| Project Description | ||
| Summarize the overall program/project to be funded by this request. How will this program advance your mission? Please provide a short and clear statement about what you propose to do with funds from the Bruening Foundation. Including the number of clients to be served. This should be a summary. You will give more detailed information about goals, activities and outcomes below. (150 word limit) | ||
| Numbers served by program/project | ||
| How many individuals will be served by this program/project? | ||
| Project Budget | ||
| What is the total cost of the program/project? Whole numbers only. | ||
| Per person costs | ||
| What is the per person cost of this program/project? | ||
| Income sources for budget | ||
| What dollar amount of the program/project budget do you anticipate will come from charitable and philanthropic contributions (either individual donations or foundation grants)? All income sources should be outlined on the budget that is attached. | ||
Goals and Objectives | ||
| List the goals and objectives for the program/project, i.e., what do you hope to achieve? Goals are broad, strategic intentions; and objectives are narrow, precise tactics to achieve those goals. Select the three most significant and enter them into the fields below. | ||
| 1. Goal/Objectives | ||
| 2. Goal/Objectives | ||
| 3. Goal/Objectives | ||
| Activities | ||
| List the activities for the program/project, i.e., what will you do to achieve the goals listed above? Please be specific and include numbers to be served, services provided, staff who will provide services, locations and timeframe. (200 word limit) | ||
| Outcomes | ||
| List the outcomes you hope to achieve with the program/project, i.e., how will you measure success and if you reached your goals listed above? Please be specific, including what staff, tools or other resources will be used to measure outcomes. (100 word limit) | ||
| Impact | ||
| What impact and/or change do you expect in your organization and/or the community as a result of this program/project? (word limit 100) | ||
| Evidence of Success/Accomplishments | ||
| What data or evidence suggests that this approach will be effective? Responses may include information about numbers of clients served in the past by this program/project, use of best practices, evaluation data, or organization or program accomplishments. (100 word limit) | ||
| Sustainability | ||
| If successful, how will you sustain this program/project in the future? (100 word limit) | ||
| Fit with Foundation's Priorities | ||
| How does this program/project fit with Bruening Foundation's stated interest of addressing the educational, employment and basic human needs of those living in poverty? Why is funding from the Bruening Foundation critical to the success of this program/project? (150 word limit) | ||