Network Partner Grant Application

About Your Organization

Organization Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Name *

Title *

Phone *

Email *

Counties Served (for multiple counties, CTRL+Click or Command+Click) *

Did you attend the informational webinar held on February 17, 2023? *

Yes
No
I watched the recording of the informational webinar

Briefly describe your organization, its mission, and its work. Be sure to highlight your early childhood programs. *

Specify the type of organization: *

Non-Profit Organization
Community-Based Organization
Tribal Organization
Other

If you selected "other", please describe.

Please upload your 501c3 determination letter.

Click or drag a file to this area to upload.

Please describe the community you serve. *

What is the target population your organization serves? *

How many children birth through age 5 does your organization serve? *

With which of the following sectors does your organization routinely engage? *

Early Care and Education Providers
Home Visitation Programs
Family/Child Advocates
Health and Human Services Agencies
Medical and/or Health Providers
Parent Educators
Early Intervention Providers
Child Welfare System- DSS
School Districts
Social Workers
Women, Infants, and Children (WIC) Nutrition Program
Faith-Based Initiatives
Child and Family Legal Services
Intimate Partner Violence Prevention Groups
Other (please specify)

What previous experience has your organization had working with HMG SC? *

What is your organization's capacity to implement the following activities. *

	None	Little	Some	Significant
Promote healthy child development in partnership with HMG SC	Promote healthy child development in partnership with HMG SC None	Promote healthy child development in partnership with HMG SC Little	Promote healthy child development in partnership with HMG SC Some	Promote healthy child development in partnership with HMG SC Significant
Connect families to developmental and behavioral health screenings through HMG SC.	Connect families to developmental and behavioral health screenings through HMG SC. None	Connect families to developmental and behavioral health screenings through HMG SC. Little	Connect families to developmental and behavioral health screenings through HMG SC. Some	Connect families to developmental and behavioral health screenings through HMG SC. Significant
Lead community screening events using the HMG SC Read Rattle & Roll model.	Lead community screening events using the HMG SC Read Rattle & Roll model. None	Lead community screening events using the HMG SC Read Rattle & Roll model. Little	Lead community screening events using the HMG SC Read Rattle & Roll model. Some	Lead community screening events using the HMG SC Read Rattle & Roll model. Significant
Facilitate cross-sector partnerships that introduce HMG SC to your service area.	Facilitate cross-sector partnerships that introduce HMG SC to your service area. None	Facilitate cross-sector partnerships that introduce HMG SC to your service area. Little	Facilitate cross-sector partnerships that introduce HMG SC to your service area. Some	Facilitate cross-sector partnerships that introduce HMG SC to your service area. Significant
Explore and identify community resources that serve young children and share them with HMG SC.	Explore and identify community resources that serve young children and share them with HMG SC. None	Explore and identify community resources that serve young children and share them with HMG SC. Little	Explore and identify community resources that serve young children and share them with HMG SC. Some	Explore and identify community resources that serve young children and share them with HMG SC. Significant
Document outreach activities in the HMG SC data system.	Document outreach activities in the HMG SC data system. None	Document outreach activities in the HMG SC data system. Little	Document outreach activities in the HMG SC data system. Some	Document outreach activities in the HMG SC data system. Significant

Provide a detailed description of how your organization would partner with HMG SC to promote healthy child development through at least two of the above activities. Please include specific goals and objectives on how you would implement these activities. *

Please provide details on how you plan to use this funding to support these goals and objectives. *

What existing resources do you have to dedicate to this project? *

How many additional children birth to age five do you feel you will reach through this project? *

What is your organization's experience leading similar initiatives? *

Is there anything else about your organization that you would like us to know?

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