Woodruff Foundation Application

    Organization Information


Organization Name 

 		 
Address 

 


 
City 

 		 
State 

 		<Select One> 
Zip Code 

 		 
Phone 

 		 
Website 

 		 
Federal Tax ID 

 		0000 
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 (indicate year of most recent service figures): individual counseling--short term services provided by an LISW for adults (60 served) and teens (20 served); group counseling -- weekly groups led by an LISW for teens who have experienced trauma (30 served); outreach and prevention -- weekly visits to health classes at neighborhood middle schools to teach alcohol and other drug refusal skills (100 served) 

 







 

    Client Demographic Information

 
The information in this section should reflect the overall client population. Enter whole numbers only and do not use a % sign. If an answer is unknown or not applicable to your organization 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% Refresh 
Percentage female 
Whole number only, no percent sign 

 		 
Percentage male 
Whole number only, no percent sign 

 		 
Percentage of low income clients served 
If you collect income information about your clients, give the percentage of clients served who are below 150% of federal poverty level based on the Health and Human Services Poverty Guidelines. Enter a whole number only and do not use a percent sign. If your organization does not collect this information, enter N/A here. 

 
 
Description of Clients Served 
Provide any other information not reflected in the numbers above about the population you serve. (100 word limit) 

 



 

    Contact Information


    Executive Director/President/CEO

 
Prefix 
Example: Mr., Ms. 

 		 
First Name 

 		 
Last Name 

 		 
Title 

 		 
Office Phone 

 		 
Extension 

 		 
E-mail 

 		 

    Primary Contact for Request

 
Same as above 

 		 
Prefix 

 		 
First Name 

 		 
Last Name 

 		 
Title 

 		 
Office Phone 

 		 
Extension 

 		 
E-mail 

 		 

    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; to provide benefits eligibility screening 

 
 
Project Start Date 

 		 
Project End Date 

 		 
Length of grant 
(In whole months) 

 		 
Project Description 
Summarize the overall program/project to be funded by this request. Please provide a short and clear statement about what you propose to do with funds from the Woodruff Foundation. This should be a summary. You will give more detailed information about goals, activities and outcomes below. (100 word limit) 

 





 
Foundation Focus Areas 
How does your project directly address the Woodruff Foundation's efforts to encourage the implementation of innovative prevention and treatment programs, strengthen the effectiveness of existing service delivery systems, or otherwise respond to changes in the environment for behavioral health care services? (100 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. 

 		 

    Goals and Objectives

 
List the goals and objectives for the program/project, i.e., what do you hope to achieve? Select the three most significant goals or objectives 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 determine 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) 

 



 
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)