You can save a draft of your application and return at a later date. Please remember to save often. Welcome! Organization Name Contact Person Mailing Address Telephone Fax Email Website Program Name Brief Description Total Program Budget Total United Way Funding Requested Other Funding Sources Coalition - None -Yes No Coalition Members Fiscal Agent Mission History Fundraising Legal Actions - None -Yes No Legal Explanation Focus Area(s) - None - Reducing rates of substance abuse through prevention, education, and treatment Increasing awareness and access to mental health services Supporting life-long healthy choices Community Need Root Cause Target Audience Program Services Dashboard Indicators Using Outcome Measures Outcome Success Story (Optional) Success Story Photo 2017 Clients Served 2017 Touches 2019 Client Projections 2019 Touches Projection Age Communities Served Ethnicity Gender Income Demographic Data Program Budget Logic Model Attachments Outcome Measurement Tool 1 Application Attachments Outcome Measurement Tool 2 Board of Directors List Proof of Non-Profit Status (Optional) Additional Information Male Low Income Female Low to Moderate Income Unknown Above Moderate Income Asian Under 5 Black 6-12 Allenton Hispanic 13-18 Colgate Indian 19-26 Germantown White 27-64 Hartford Other 65-80 Hubertus 81 and Over Jackson Kewaskum Newburg Richfield Slinger West Bend Rest of Washington County Non-Washington County Submit Leave this field blank
