Community Partnership Application

Agency Information

*Name of Agency

Tax Exempt Organization Number

*Street Address

*City

*State

*Zip Code

Website

*Executive Director/Board Chair

*Is the agency a past JLT Community or IMPACT Partner? If yes, what was the project?

*Agency Mission Statement

*Agency Vision/Impact Statement

*How does this organization's mission/vision/values align with the Junior League of Tulsa's stated mission and impact areas?

Contact Information

*Agency Contact Name

*Agency Contact Title

*Contact Phone Number

*Contact Email

Contact Fax

Project Objectives

*State the project's objectives/goals/outcomes in order of priority

*What criteria have been established to evaluate the project's success? (i.e. # of people served, hours worked, duties completed, beneficiary feedback)

The project will: (please check all that apply)

Establish a new service or program

Expand an existing service or program

Other (please explain)

*This project will meet the following specific community need(s):

*Explain how these needs were determined (sources, statistics, etc.)

Project Information

*Description of Project

*Proposed Start Date

*Proposed End Date

*Anticipated total length of project
Short term (1-2 years) Long term (3+ years)

Time of day when volunteers are needed

Daytime

Evening

If both, please give projected distribution of volunteer shifts:

% days

% evenings

*Is specific paperwork/background check/vaccination/training required for JLT members to participate in this project? (if yes, please describe)

*Number of JLT volunteers requested

*Funding requested

*Please explain the skills necessary for the volunteer position

*Please give a brief job description for potential volunteers (include days of week, hours per shift, duties to be performed, location of services to be provided)

Please attach the following agency documents

*List of Board of Directors

*Annual Report

Any relevant collateral or promotional information

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