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
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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)
Other
Will partial funding be provided by any of the above sources?
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Yes
No
Maybe
Student Information
Student's Last Name
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Student's First Name
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Student's Date of Birth
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-
Month
-
Day
Year
Date
Zip Code
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What gender does the student identify with?
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Male
Female
Other
What race/ethnicity does the student identify with?
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Hispanic
Black
White
Native American
Asian
Pacific Islander
Mixed
Does the student have a disability?
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Yes
No
Unknown
School Attending
Preschool
Ayres
Campbell
Sterling Middle School
Sterling High School
Caliche
Fleming
Merino
Peetz
Goal Academy
GED
Other
Parent Name
Siblings in the Family
Rows
Name of Sibling
Sibling
Sibling
Sibling
Sibling
Sibling
Victim Status of the Student
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Victim in a criminal protection order or JD or criminal case
Recipient of Victim’s Compensation
Protected party in a protection order
None of the above
Unknown
Grade Level
Pre-School
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
GED
Other
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
Restitution/Learn from mistake(s)
Other
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)?
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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?
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School Administrator
School Support Staff
Teacher
Private Practice Counselor
Juvenile Justice Supervision
Athletic Coach
Mentor
Parent
Other
Purpose of Funding
Purpose of Funding (if more than one, select all that apply)
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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
Other
How will this funding help the student succeed with their goal?
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Please be as specific as possible
Funding Details
What is the total dollar amount needed?
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Which of the following payment options are preferred?
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Walmart Gift Card
YouthLink check(s)
Gift Card(s) - specify in comments
Online purchase
Cooperative Ministries Voucher
Other
Please attach any documentation needed (such as a receipt for reimbursement)
Browse Files
Cancel
of
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.
(If applicable) Please provide a shipping address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referral Source Info
Name of person making this request
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Your Email
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example@example.com
Your Phone Number
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Area Code
Phone Number
What is your role with this student(s)?
School Staff
Mental Health Provider (outside of school)
Juvenile Justice
Diversion
Mentor
Family Resource Center
Parent
Other
Submit
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