Survey & Form Center

2. 
4. Important
   To submit this form you do not have to sign in or create a Form Center account above. However, you will have to complete the form in its entirety without the option to save your progress unless you do create an account.
6. Creating A Form Center Account
   » Form Center Creation Instructions

   Use this link for instructions about how to create a Form Center account. Creating an account will enable you to save your progress while completing a form.
8. Submission Deadline
   Completed applications must be submitted no later than 4:00 p.m. (central) on Friday, April 23, 2021.
10. FUNDING REQUEST AMOUNT*
12. Name Of Your Organization/Agency*
14. Name Of Program/Project*
16. Address Agency*
18. City*
19. State*
20. Zip*
22. Agency Phone Number*
23. Agency Website
25. COMBAT Program Director
    Individual who will directing program that would receive COMBAT funding
27. Name*
29. Phone Number*
30. email*
32. Organization's Executive Director
34. Name*
36. Phone*
37. email*
41. Anti-Violence Area Of Focus
    Please select which of these issues your agency will address.
43. Youth Employment

    1. Youth Emloyment Checkbox

    COMBAT is seeking proposals that focus on hiring youth 13-17 to work in their communities from June 2021 to June 2022.
45. Domestic Violence

    1. Domestic Violence Checkbox

    COMBAT is seeking to fund proposals that will provide essential services for domestic violence and sexual assault survivors, in addition to domestic violence prevention programs that promote healthy relationship skills. A point of emphasis is Trauma Counseling for survivors , their children and any potential witnesses, with counseling made available as immediately as possible following the domestic violence and/or sexual violence occurrence. We will also fund programs that focus on assuring that survivors are fully informed of all resources and services available to them, including counseling, sheltering and victim advocacy.
49. 1) Is this an existing program for your agency?*

    1. Yes
    2. No
51. 2) Is this program currently funded by COMBAT?*

    1. Yes
    2. No
52. If yes, for how long?*
54. 3) What is your overall Vision for what your project will accomplish related to this funding request?*
56. 4) Program Summary
    Describe your proposed Anti-Violence/Anti-Drug Prevention program based on your selected area of focus. If funded, this will be the program description used by COMBAT on our website and publications about our funded programs. Address the purpose, target population, services/activities to be provided and expected outcome of your program.
58. Program Summary*
62. Program Description
64. 1) Please Discuss Program Purpose Statement
    The purpose of a program is to achieve outcomes. It is driven by audience needs and considerations (for whom). It provides a solution to meet those needs (what we do). It fulfills the organization's mission. It defines audience, activities, services, and outcomes.
66. Purpose Statement*
68. 2) Please Discuss Program Goal(s)
    Goals are typically broad general statements that describe what the program plans to accomplish. Goals establish the overall direction for and focus of a program. Goals define the scope of what the program should achieve and serve as the foundation for developing program objectives.
70. Program Goals*
72. 3) Please Discuss The Need
    What problem or opportunity does the program addresses? Who experiences it?
74. Needs*
76. 4) List prevalent risk-factors that will be addressed in your 2021 proposal:*
78. 5) List which protective-factors will be utilized in buffering prevalent risk-factors:*
80. 6) EXPECTED EFFECTS: What changes resulting from the program are anticipated?*
82. 7) EXPECTED EFFECTS: What must the program accomplish to be considered successful?*
84. 8) INTERVENTION ACTIVITIES: What steps, strategies, or actions will the program take to effect change?*
88. Schedule & Location(s)
90. Will the program be offered year-round?*

    1. Yes
    2. No
92. What days of the week will the program will be offered?*

    1. Monday
    2. Tuesday
    3. Wednesday
    4. Thursday
    5. Friday
    6. Saturday
    7. Sunday

    Check all that apply
93. What times will your program be offered?*
95. Will you program/project be at one site or multiple sites?*

    1. One Site
    2. Multiple Sites
97. Program/Project Location
99. Location Type*
    -- Select One --Community-Based AgencyCommunity CenterCommunity Mental Health CenterSubstance Abuse AgencySchoolChurchOther
100. Other*
     If you selected other under "Location Type," specify that location type here.
102. Name
     Include name of commuinity center, school, church, etc. if applicable.
104. Physical Address*
106. City*
107. State*
108. Zip*
110. Program Phone*
112. More Locations (List ALL Below)
114. Include name of facility, address, city, state and zip
118. Target Population
     List age, ethnic breakdown, gender, and geographic area to be served. Describe your outreach strategy and how clients will be recruited. If referred from other agency(ies), you must include a letter stating that these agencies are aware that they will be part of a COMBAT project, as an Appendix to your proposal. Failure to provide current proof of referring partner will result in 10-point deduction.
120. Age
122. Ages 0-5
     % In This Age Group
123. Ages 6-12
     % In This Age Group
124. Ages 13-17
     % In This Age Group
125. Ages 18-24
     % In This Age Group
127. Ages 25-35
     % In This Age Group
128. Ages 36-44
     % In This Age Group
129. Ages 45-60
     % In This Age Group
130. Over 60
     % In This Age Group
132. Gender
134. Male
     % Of Male Clients
135. Female
     % Of Female Clients
137. Ethnicity
     Percentage of clients expected to serve from each of these ethnic/racial groups.
139. Hispanic or Latino
140. White
     (Not Hispanic or Latino)
141. Black or African American
143. American Indian/Alaska Native
144. Native Hawaiian
     (Or Other Pacific Islander)
145. Asian
147. Two or More Races
149. Geography
151. Geographical Area Program/Project Will Serve
153. Estimates
155. Estimated Number To Be Served?*
156. Estimated Cost Per Person?*
160. How does your staff breakdown match your target population? *
162. Describe outreach strategy and how clients will be recruited. Be very specific and make connection with needs listed under "Program Description."*
166. Key Partners
     Who are your key partners who will enhance your ability to conduct this project? Describe their role(s) related to the project and expertise as well. You must include a current letter stating that these partners are aware that they will be part of a COMBAT project.
168. Key Partners
170. Partner Letter 1
171. Partner Letter 2
173. Partner Letter 3
174. Partner Letter 4
178. Staff Expertise & Experience
     Describe the experience and expertise of key staff (and contract positions) for the proposed project (including experience or training in selected strategies). Identify the person who will be the Coordinator/COMBAT Program contact and other staff. Include job descriptions for each staff or contract person
180. Key Staff*
184. 2021 Program Budget Information
186. Personnel (Salaries)
188. COMBAT Budget
     Proposed
189. Other
     Other Funding Amount
190. Total
     Total Cost
191. Funding Sources
     Number of Other Sources
193. Fringe Benefits
     Maximum 10% of Salaries (Describe Benefits Below)
195. COMBAT Budget
     Proposed
196. Other
     Other Funding Amount
197. Total
     Total Cost
198. Funding Sources
     Number of Other Sources
200. Description of Fringe Benefits
202. Auditing/Accounting Services
204. COMBAT Budget
     Proposed
205. Other
     Other Funding Amount
206. Total
     Total Cost
207. Funding Sources
     Number of Other Sources
209. Evaluation
211. COMBAT Budget
     Propsed
212. Other
     Other Funding Amount
213. Total
     Total Cost
214. Funding Sources
     Number of Other Sources
216. Postage
218. COMBAT Budget
     Proposed
219. Other
     Other Funding Amount
220. Total
     Total Cost
221. Funding Sources
     Number of Other Sources
223. Printing
225. COMBAT Budget
     Proposed
226. Other
     Other Funding Amount
227. Total
     Total Cost
228. Funding Sources
     Number of Other Sources
230. Meeting Expense
232. COMBAT Budget
     Proposed
233. Other
     Other Funding Amount
234. Total
     Total Cost
235. Funding Sources
     Number of Other Sources
237. Mileage (Local Travel)
239. COMBAT Budget
     Proposed
240. Other
     Other Funding Amoung
241. Total
     Total Cost
242. Funding Sources
     Number of Other Sources
244. Training
246. COMBAT Budget
     Proposed
247. Other
     Other Funding Amount
248. Total
     Total Cost
249. Funding Sources
     Number of Other Sources
251. Stipends
253. COMBAT Budget
     Proposed
254. Other
     Other Funding Amount
255. Total
     Total Cost
256. Funding Sources
     Number of Other Sources
258. Insurance
260. COMBAT Budget
     Proposed
261. Other
     Other Funding Amount
262. Total
     Total Cost
263. Funding Sources
     Number of Other Sources
265. Other
267. COMBAT Budget
     Proposed
268. Other
     Other Funding Amount
269. Total
     Total Cost
270. Funding Sources
     Number of Other Sources
272. Specify
274. Other
276. COMBAT Budget
     Proposed
277. Other
     Other Funding Amount
278. Total
     Total Cost
279. Funding Sources
     Number of Other Sources
281. Specify
283. Other
285. COMBAT Budget
     Proposed
286. Other
     Other Funding Amount
287. Total
     Total Cost
288. Funding Sources
     Number of Other Sources
290. Specify
292. Other
294. COMBAT Budget
     Proposed
295. Other
     Other Funding Amount
296. Total
     Total Cost
297. Funding Sources
     Number of Other Services
299. Specify
301. Other
303. COMBAT Budget
     Proposed
304. Other
     Other Funding Amount
305. Total
     Total Cost
306. Funding Sources
     Number of Other Services
308. TOTAL PROPOSED BUDGET
310. COMBAT Budget
     Proposed
311. Other
     Other Funding Amount
312. Total
     Total Cost
313. Funding Sources
     Number of Other Sources
317. Required Documents
319. Attachment
     Jackson County Compliance Report Form completed and signed or existing certificate (if you have one). Download This Form (PDF)
320. Attachment
     Copy of Paid Jackson County Property tax receipt or current exemption certificate.
322. Attachment
     Copy of evidence of liability insurance coverage for at least $1 million.
323. Attachment
     Copy of current IRS Form 990 (within past two fiscal years 2018 or 2019).
325. Attachment
     Copy of full Certified Financial Audit (within past two fiscal years 2018 or 2019).
326. Attachment
     Copy of letter indicating current IRS 501(c)(3) tax-exempt status (if applicant is not a governmental agency, e.g., city, school district or court in Jackson County).
328. Attachment
     Certificate of Good Standing from the Missouri Secretary of State.
329. Attachment
     List of Staff with titles and copies of certifications
331. Attachment
     List of Board of Directors
335. Acknowledgement*

     By clicking "Agree," you agree and acknowledge that information and statements provided in this application are, to the best of your knowledge, true and accurate.

     1. Agree
337. By typing your name in the "Signature" box below, you acknowledge that this "electronic signature" is valid and binding upon you to the same force and effect of a traditional handwritten signature.
339. Signature*
340. Date*
     Date
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342. 1. Receive an email copy of this form.
343. Email address

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344. Submit

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