HomeAid North Texas Care Day Application
Most Care Days are one- or two-day events. HomeAid North Texas strives to provide these at no cost to our service provider partners, but that cannot be guaranteed. Costs will be figured out together ahead of time. To be considered, we must have all of the information requested below before the first meeting with leadership of both organizations.
Date
*
-
Month
-
Day
Year
Date
Organization's Name
*
Organization's Website
*
Organization Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Executive Director / CEO
*
First Name
Last Name
ED/CEO's Phone Number (Mobile Preferred)
*
Please enter a valid phone number.
ED/CEO's Email
*
example@example.com
Key Contact (if not the Executive Director/CEO)
First Name
Last Name
Key Contact's Phone Number (Mobile Preferred)
Please enter a valid phone number.
Key Contact's Email
example@example.com
Is the Organization a 501(c)3
Yes
No
Tax ID Number
*
Upload a copy of your 501(c)3 Determination Letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Organization's Vision Statement
Organization's Mission Statement
Current programs/services:
How long has your organization been in operation?
Optional: Upload a brochure or flyer about your organization:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Population served (check all that apply):
Abused Children
Adults - Substance Abuse
Adults w/Aids
Children/Youth
Chronic Homeless
Developmentally Disabled
Domestic Violence
Emancipated Youth
Families
Human Trafficking
Kinship
Men
Older Adults/Seniors
Pregnant Minors and their children
Reentry/Second Chance
Sex Trafficking Victims
Veterans
Women
Women and Children
Young Adults 18-22
Youth with Diabilities
Other
Support Services you provide (check all that apply):
Outreach
Case Management
Addiction Rehabilitation
Mental Health Services
HIV/AIDS-related programs
Education
Employment Assistance
Childcare
Transportation Assistance
Legal
Life Skills (aside from Case Management)
Other
What is your agency’s current annual operating budget?
Please list your three major sources of operating income (government funding, grants, corporate, individuals, specific foundations, etc.):
Project Information:
List, prioritize and describe up to four critical repairs or cosmetic upgrades needed at your facility
Project #1
Project #2
Project #3
Project #4
Do you carry Property Insurance?
Yes
No
Do you carry Liability Insurance?
Yes
No
Do you own the work-site building
Yes
No
If not, are you allowed per your lease to make physical changes to the location?
Yes
No
Can you provide the lease or written agreement from the landlord if requested?
Yes
No
Any other pertinent information regarding your lease?
Project Address (if different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Project Contact (if different from above):
First Name
Last Name
Project Contact's Email (if different from above):
example@example.com
Project Contact's Mobile number (if different from above):
Please enter a valid phone number.
How many, if any, new beds will the HomeAid project add?
How long can people stay at your facility (if applicable)?
Individuals Served Annually:
How did you hear about HomeAid North Texas?
If HomeAid partners on this project, HomeAid will ask you to share a couple of success stories about your clients (no names required) and may ask for demographic information about the people you serve. Would you be willing to share this?
Yes
No
May HomeAid North Texas take general photos and videos of the project site, volunteers, and the finished work for marketing and promotional purposes?
Yes
No
If a client success story is shared, may we arrange to have a photo or video of that client (with their full consent and a signed release form) to include with the story?
Yes
No
Thank you for thinking of HomeAid North Texas!
We look forward to speaking with you soon. For questions or comments, please contact David Belloc at info@homeaidnorthtexas.org or 817-705-8269
Submit
Should be Empty: