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 age 21 & under.
The student has at least one school-related goal.
You (or another adult) will work with the student to provide "goal coaching" and assist them in achieving a successful outcome.
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 (TANF, Diversion, PA3, core services, etc.)
Grants (CTC, Heads Up, Sources of Strength, etc.)
Centennial Mental Health (housing, mentoring, etc.)
Northeast Colorado Health Department
Family Resource Center (CCR or other program)
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)
Behavior (at school or home)
Learn from mistake(s)
Restitution for mistake(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)
Probation Officer (13th JD)
Family Resource Center
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?
Walmart Gift Card
Gift Card(s) - specify in comments
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.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service