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.
These criteria are required by YouthLink for approval of funding requests. Please check each that is true for this youth.
Funds will benefit a Logan County student (K-12 or GED) age 21 & under
The student has at least one written goal and has a "goal coach" (an adult who will help them be successful)
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
In-house funding (your organization)
Dept. of Human Services
City of Sterling
Centennial Mental Health
Advantage Treatment Center
Northeast Colorado Health Department
Life Source (mental health services when at-risk for suicide)
Church (if applicable)
Will partial funding be provided by any of the above sources?
Student's Last Name
Student's First Name
Student's Birth Date
Sterling Middle School
Sterling High School
Student Goal Area(s)
What is the student's goal(s)?
What is the target date for completing the goal?
Who is the student's Goal Coach?
Name of person making this request
What is your role with this student(s)?
School Support staff (liaison, nurse, etc.)
Counselor (outside of school)
Case Manager (MH)
Case Manager (CW)
Case Manager (SB-94)
Family Resource Center
Probation Officer (13th JD)
Purpose of Funding
Activities & Sports
Health (Hygeine, medical, etc)
Supplies/Food for event or program
Incentive/Reward for goals - Education
Incentive/Reward for goals - Behavior
What is the total dollar amount needed?
Which of the following payment options are preferred?
Cooperative Ministries Voucher
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.
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