TEAM UP for Success Funding Request

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. *

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's Last Name
Student's First Name
Student's Birth Date

Month Day Year
Date
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 Goal Area(s)

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)
What is the student's goal(s)?
What is the target date for completing the goal?

Month Day Year
Date
Who is the student's Goal Coach? *
Name of person making this request *
Your Email *
example@example.com
Your Phone Number

Area Code Phone Number
What is your role with this student(s)?

Parent 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
Purpose of Funding

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
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.
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YouthLink TEAM Up for Success Funding Request