SUMMER 2017 APPLICATION FOR DFI TITLE XX CAMPING SERVICES

Transcription

1 SUMMER 2017 APPLICATION FOR DFI TITLE XX CAMPING SERVICES *Funding provided in part by the Illinois Department of Human Services. Thank you for your interest in joining the American Association, Illinois and the Illinois Department of Human Services through the DFI Title XX ing Services Program. Please complete this application fully and to the best of your knowledge. Applications can be submitted by scanning attachments through , fax, postal mail or in person. Each application must include more than one employee s name, including the person with authority to sign legal documents. At least two different phone numbers and s must be provided for each agency. Each agency should complete one application, listing each camp or site separately in the appropriate section. One application will be accepted per agency, per summer. Deadline to submit an application is February 1, 201 Applications should be sent directly to: By (Preferred): Carlise@acail.org By Postal Address or In Person: ACA Illinois, 5 S Wabash Ave. STE 1406, Chicago, IL, By Fax: Questions about the application process can be directed to Carlise Willis at Carlise@acail.org or by phone at ex 2 More information can be found at To Be Completed by a Person with Authority to Sign Legal Documents Name of Agency: I affirm that the information found on the application is correct to my knowledge. I understand that submission of this application does not guarantee that this application for allocation of funds will be granted. I also understand that the Illinois Department of Human Services has the right to terminate the program and the funding at anytime. My agency will not discriminate against campers, families or employees who are a part federally or state protected group. Signature: Printed Signature: Title: Date:

2 Agency Profile Name of Agency: Agency Mailing Address: City: State: Zip: Executive/CEO Name: Executive/CEO COO/CFO Name: COO/CFO The Executive/CEO is the person ultimately responsible for the agency and able to sign contracts and agreements. Each camp must have second name listed, someone who is authorized to submit bills and answer questions in the absence of the Executive/CEO. Payment & Billing Profile Name of Person who Handles Processing and Receiving Payments: Make Checks Payable to: Mailing Address for Check: City: State: Zip: for the Person Handling Processing and Receiving Payment: s/sites Please list each specific site or camp used by the agency, that will include campers through the DFI Title XX program. If there are more than two sites/camps for the agency, please attach additional attachment with complete information for each site. /Site #1 Name of : Mailing Address: City: State: Zip: Director Name: Director Area Served (City, County, Region of State, or Zip Codes): Type of : Residential Resident Special Needs Day Day Special Needs /Site #2 Name of : Mailing Address: City: State: Zip: Director Name: Director Area Served (City, County, Region of State, or Zip Codes): Type of : Residential Resident Special Needs Day Day Special Needs

3 Dates: REQUESTED ALLOCATIONS FOR SUMMER 2017 JUNE 2017 ers This ( ers) x ( ) Dates: JULY 2017 ers This ( ers) x ( )

4 Dates: AUGUST 2017 ers This ( ers) x ( ) Dates: OTHER 2017 ers This ( ers) x ( )

5 Affirmation of Cost Per er Supply the actual cost of serving campers using the following formula: cost of all expenses related to summer day or resident camp divided by the total number of camper days or camper nights, using all campers. Day : Summer Expense (Minus Government Funded Items) er Days = Per er Day Resident : Summer Expense (Minus Government Funded Items) er Nights= Per er Night I affirm that the per camper cost shown above accurately reflects our true cost. In signing this I or we understand that the above per night or per day figure may need to be confirmed by an audit. I affirm that the above-entered cost figures are not more than our actual costs after deductions directly related to government funded. Signature: Printed Signature: Title: Date: er, Participant & Program Information Ages of ers the /Agency Serves: Gender of ers Served: Does the camp have a specific program focus? /Agency s Mission Statement: Please list your top five program areas that your camp is known for or best at: /Agency Website: Does the or the Family Provide Transportation (Please Describe): Please list all the counties/cities/zip codes your camp/agency serves through the camps/sites listed on this application: