SERVICE DELIVERY AGREEMENT by HC12083017279

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									                                                                United Way of Thunder Bay
                                                                        1093 Barton Street
                                                               Thunder Bay, On P7B 5N3
                                                                      Phone:(807)623-6420
                                                                        Fax:(807)623-6180
                                                              email@unitedway-tbay.on.ca
                                                               www.unitedway-tbay.on.ca




MEMORANDUM




TO:   Charitable Service Organizations in Thunder Bay


FROM: Joanne Kembel, Executive Director, United Way of Thunder Bay


RE:   United Way of Thunder Bay Funding
      New Applicant Pre-Allocation Form for 2013



The United Way of Thunder Bay is inviting new applicant, charitable agencies to
review and if appropriate, submit a Pre-Allocation Submission Form to our office by
April 2, 2012.


Prior to completing this form we would recommend you complete the United Way
Funding Criteria Checklist (page 2 of the Pre-Allocation Form) and set up a
meeting with myself, Joanne Kembel, to discuss eligibility, the form and process.
You may contact me at 626-1754 or jkembel@unitedway-tbay.on.ca


This application is part one of the new applicant allocation process. Your
submission will be reviewed by the United Way Allocations Committee to determine
if your program or service is eligible to be considered for funding in the agency
allocation process. You may also be asked to meet with the United Way
Allocations Committee prior to a decision being made.
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If you are successful, you will be invited to submit a full funding application. The
complete Allocation Submission Form can be found on the United Way website at
www.unitedway-tbay.on.ca on April 26th, 2012.




                                    UNITED WAY

                                 NEW APPLICANT

                                        2013
                      PRE - ALLOCATION SUBMISSION

Prior to completing this application we recommend you review this form, complete
the United Way Funding Criteria Checklist (page 2) and set up a meeting with Joanne
Kembel, Executive Director at the United Way (626-1754) to discuss eligibility, the
form and process.

This application is part one of the new applicant allocation process. Your
submission will be reviewed by the United Way Allocations Committee to determine if
your program or service is eligible to be considered for funding in the agency
allocation process. You may also be asked to meet with the United Way Allocations
Committee prior to a decision being made. If you are successful, you will be invited to
submit a full funding application which will be on our website April 26th, 2012.

  10 COPIES OF YOUR FULLY COMPLETED SUBMISSION MUST BE DELIVERED TO
   THE UNITED WAY OFFICE BY April 2nd, 2012 along with the following documents:

INDICATE THAT THE FOLLOWING DOCUMENTS ARE FULLY COMPLETED AND
ENCLOSED WITH YOUR SUBMISSION:

    1 Copy of your list of 2013 Board of Directors
    10 Copies of your most recent annual report

     10 Copies of your most current Audited or Reviewed Financial Statement:
      Current Management Statements should be included with submission if the
      Current Financial Statements are not available (Audited or reviewed statements
      must be submitted to the United Way when they are available)

AGENCY: ___________________________________________________

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PRESIDENT or TREASURER: _________________________ ____________________
                                                Signature                            Print

YEAR YOU ARE REQUESTING FUNDING FOR: _________________

SUBMISSION DATE: __________________


   The above certify the figures submitted are correct and have included all the required attachments.




                            UNITED WAY OF THUNDER BAY
                                   FUNDING CRITERIA
Agency is a registered charitable organization. Yes____ No____

Agency has a Board of Directors. Yes ____ No ____

CRITERION I: NEED

The agency program is responding to: Changes in the community including cultural
patterns and/or trends in the provision of service to clients, and to high need groups
or persons living in high need areas.

There is an identified need for the agency's program. Yes _____ No _____

Agency has used a process that documents this need. Yes_____ No_____

Program falls within one of the United Way’s Fields of Service. Yes___ No____

Agency can describe how the program fits within the Field of Service Yes ____ No____


CRITERION II: PROGRAM EFFICIENCY AND EFFECTIVENESS

The agency is accountable for providing a high quality service in the most efficient
way possible. It views program evaluation as an essential process to ensure the
most optimum use of resources.

Agency has a clear mission statement. Yes ____ No______

Agency has overall goals that flow from this mission and specific objectives for each program
they are requesting funding. Yes _____ No _____

There is no duplication of this program within the community. Yes_____ No _____

Agency shows how it collaborates with other agencies in the delivery of the program.
Yes _____ No _____


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Agency has a process in place that will measure outcomes of this program in relation to the
identified need. Yes _____ No _____

An effective process for the collection of data, which describes and monitors the program, is in
place. Yes ____ No _____

A process of program evaluation and needed changes based on recommendations is in place.
Yes _____ No_____

CRITERION III: NEED FOR UNITED WAY DOLLARS FOR SPECIFIC PROGRAMS

The agency can demonstrate through a realistic, reasonable program budgets, the financial
need for United Way funds. Yes _____ No_____

                                AGENCY PROFILE
       Agency Name:         ______________________________________________

       Address:             ______________________________________________

                            ______________________________________________

       Telephone: ________________________                 Fax: ______________________

       Website address: _________________________________________

       Charitable No: ____________________________________

       Incorporation Date: _______________________________

       Agency Fiscal Year End: ____________________________

       Contact Person in regards to this submission:

       Name: ________________________ Position: _________________________

       Direct Telephone #: ______________

       E-Mail Address: _______________________



       Mission Statement of Organization:




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      **Please attach a list of your 2013 Board of Directors



     2013 United Way Funding Request for Program:

                          $____________________



                             Program Description
     *Complete One Schedule 2 for each Program for which you are requesting funding.



Name of the Program: __________________________________________

Agency Name: __________________________________________________
Is this program an approved Revenue Canada Charitable Activity and in-line with
your organization’s Charitable Objects?
                   Yes ______ No _______


a)   i. Description of the Program including what United Way funds will be used for.
     (Program objectives, target population, main activities, days and hours of
     operation per week, objectives for program etc):




b)   Field of Service (check off which box is most applicable to your program.)

    From Poverty To Possibility: (Moving People out of and Preventing Poverty by
     enhancing Life Skills & meeting basic human needs)

    Healthy People, Strong Communities: (Supporting Mental & Physical Health,
     Creating a strong & safe Community for All)

    All That Kids Can Be (Providing Children & Youth with support & skills for
     a Bright Future)

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c)   Please describe how your program fits within this field of service:




d) Define how the need for the program is determined (e.g. survey of clients,
   community data, and interviews):




e) To your knowledge, is there any other local agency offering a similar program?
   Yes ______ No ______

     If yes, please explain why this program is also needed:




f) 1) What other organizations or agencies do you or will you collaborate with in the
   delivery of this program?




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g) PROGRAM OUTCOMES:

Anticipated Outcomes specific to this program? (Outcomes are observable or
disclosed changes in people’s condition, status or behaviour)

What are the short term and expected long term outcomes for the clients who use
this program?      Please provide 3 for each


      1. Short Term Outcomes – (Example: person is feeling healthier due to his/her
       dietary needs being met):




     2 Long Term Outcomes –    (Example: person is living independently & is self
        sufficient):




h)   Please explain how you will evaluate these outcomes over time? (example: Data
     source: sign in sheets, surveys etc; Data collection: everyday sign in, new
     users, periodic surveys throughout the year):


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i)      Does your agency fundraise? Yes ________ No ________

        Do you fundraise between September 15th and November 15th?

        Yes ______ No _______


        How much fundraised money did you receive in the past year: ____________


        What type of fundraising activities do you carry out?




        What percentage of your over-all budget does the fund raised dollars
        represent: _________




      j) Demographic Analysis for Program:              Include client in one category only. If
      clients are not tracked by age or gender please provide your total number of clients.

                                                                       Youth/
                                            Seniors                   Children             Total
                                                          Adult
                                           60 & over                   0 – 18    Total    number
                                                       19 – 59 yrs.
                                                                        yrs              of clients
      Key: M- Male/F- Female                                                             All ages
                                           M      F     M       F     M     F    M   F      and
                                                                                          gender

     # Clients - Projected Upcoming
     Year

     Monthly Average # of Clients on
     Waiting List Over last 12 months if
     applicable to this program.




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