| Name
of Agency
The entity (for profit or not for profit) submitting the proposal must be an established agency or organization. Provide documentation of the agency such as a copy of the 501 (c)(3) professional licenses and/or other supporting material.) ญญญญญญญญญ |
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Name of Contact Person |
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Address |
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Telephone # Alternative Telephone # |
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Fax # E-Mail |
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History of the organization and the mission statement.
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Explain what services the organization currently provides.
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Number of families currently served by the organization.
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Number of current respite providers on staff and the level of care each
offer.
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Explain the demographics of the populations currently served by the
organization (age range of the clients, level of care, economic status of
the families).
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Describe how the organization is funded.
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Describe how the agency collaborates with other organizations and groups
in the community.
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Describe the populations the proposed program will serve.
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Area to be served (list towns or counties).
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Describe the proposed project.
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How will the program sustain/continue at the end of the grant period?
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How many estimated families will benefit from the program by the end of
the grant year.
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If you need additional writing space, please limit page length to 5 total pages.
BUDGET
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Account Category |
Amount |
Descriptive Information |
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Purchased Services - (such as: consultants, training fees for staff, conference registrations, interpreters) |
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Subtotal |
$0.00 |
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Supplies & Materials - (Such as: promotional materials, toys, books, videos, printing & printing supplies, postage, brochures, reference materials, manuals, translation of materials, surveys) |
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Subtotal |
$0.00 |
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Travel, Meals & Lodging - (Such as: conference/meeting/training mileage, food, motels) |
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Subtotal |
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Administrative Costs (Such as: accounting, telephone charges, salaries) |
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Subtotal |
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PROJECT TOTAL |
$0.00 |
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If you need additional writing space, please limit page length to 5 total pages.
Please return application to:
Laura Hilty
Nebraska Respite Network Across the Lifespan - North and Central Areas
626 N. Street; PO Box 509
Loup City, NE 68853
ph. 308-745-0780 x139
fax 308-745-0446
lhilty@cennecs.org