TEAM UP for Success Funding Request
Please use this form if you are a service provider (school staff, counselor, therapist, mentor, case manager, probation officer, etc.) requesting YouthLink funding for a student.
Email address *
These criteria are required by YouthLink for approval of funding requests. Please check each that is true for this youth. *
Required
Please specify other funding sources that have been explored
Will partial funding be provided by any of the above sources?
Student's Last Name
Your answer
Student's First Name
Your answer
Student's Birth Date
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School Attending
Grade Level
Student Goal Area(s)
What is the student's goal(s)?
Your answer
What is the target date for completing the goal?
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YYYY
Who is the student's Goal Coach?
Your answer
Name of person making this request *
Your answer
What is your role with this student(s)?
Purpose of Funding
What is the total dollar amount needed?
Your answer
Which of the following payment options are preferred?
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.
Your answer
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