YouthLink TEAM Up for Success Funding Request
These criteria are required by YouthLink for approval of funding requests. Please check each that is true for this youth.
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Funds will benefit a Logan County student age 21 & under.
The student has at least one school-related goal.
You (or another adult) will work with the student to provide "goal coaching" and assist them in achieving a successful outcome.
Other funding sources have been explored to pay for this service, either in full or in part.
Please specify other funding sources that have been explored
In-house funding (your organization)
Dept. of Human Services (TANF, Diversion, PA3, core services, etc.)
Medicaid
Grants (CTC, Heads Up, Sources of Strength, etc.)
Centennial Mental Health (housing, mentoring, etc.)
Northeast Colorado Health Department
Family Resource Center (CCR or other program)
Life Source (mental health services when at-risk for suicide)
Private donations
Family Members
Church (if applicable)
Will partial funding be provided by any of the above sources?
Yes
No
Maybe
Student Information
Student's Last Name
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Student's First Name
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Student's Birth Date
*
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Month
-
Day
Year
Date
What gender does the student identify with?
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Male
Female
What race/ethnicity does the student identify with?
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Hispanic
Black
White
Asian
Native American
Mixed
School Attending
Preschool
Ayres
Campbell
Sterling Middle School
Sterling High School
Caliche
Fleming
Merino
Peetz
Goal Academy
GED
Grade Level
Pre-School
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
GED
Student's Goal
Student Goal Area(s)
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Grades
School Attendance
Behavior (at school or home)
School Engagement
Social (relationships)
Mental Health
Physical Health
Job Skills
Learn from mistake(s)
Restitution for mistake(s)
Is the student working to improve a grade in a single class, or multiple classes?
One class
More than one class
All Classes
What is/are the student's current grade(s)?
What grade(s) does the student want to achieve?
How many absences does the student currently have?
What is the plan to improve this student's attendance?
What is the student's goal(s)?
Please be as specific as possible
What is the target date for completing the goal?
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Month
-
Day
Year
Date
Who is the student's Goal Coach?
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What is the Goal Coach's role with this student?
School Administrator
School Support Staff
Teacher
Athletic Coach
Private Practice Counselor
Mentor
Juvenile Justice Supervision
Purpose of Funding
Purpose of Funding (if more than one, select all that apply)
School Supplies
Clothing
Transportation
Activities & Sports
Health (Hygeine, medical, etc)
Mental Health
Educational/Tuition
Supplies/Food for event or program
Incentive/Reward for goals - Education
Incentive/Reward for goals - Behavior
How will this funding help the student succeed with their goal?
Please be as specific as possible
Funding Details
What is the total dollar amount needed?
Which of the following payment options are preferred?
Walmart Gift Card
YouthLink check(s)
Gift Card(s) - specify in comments
Online purchase
Cooperative Ministries Voucher
Notes or Comments: Please include a specific breakdown of the total amount needed, ie. $30 school supplies, $40 soccer registration; or $10 Walmart gift cards x 5, etc.
Referral Source Info
Name of person making this request
*
Your Email
*
example@example.com
Your Phone Number
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Area Code
Phone Number
What is your role with this student(s)?
School Support staff (liaison, nurse, etc.)
Teacher
Counselor (school-based)
Counselor (outside of school)
Case Manager (MH)
Case Manager (CW)
Case Manager (SB-94)
Probation Officer (13th JD)
Diversion
Mentor
Family Resource Center
Submit
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