US LACROSSE/SANKOFA LACROSSE CLINIC SERIES APPLICATION Name of Organization: Date: Street Address: Phone number: E-mail Address: Name of person completing this form: Name of organization leader (if different from the name above): If you were selected to host a clinic, where would the clinic be held? (Include the name of the field or indoor space with address of location) Preferred Clinic Dates (Please indicate your preference below. If you have no preference or have some flexibility please select all options that could potentially work for your program) Fall (August-November) Summer (June-July) Spring (April- May) Saturday Morning (between 8am-1pm EST) Saturday Afternoon (between 2pm-6pm EST) Sunday Morning (between 8am-1pm EST) Sunday Afternoon (between 2pm-6pm EST) Two clinics* One clinic (*Opportunity only available for programs with more than 100 participants only!)
Please check all that apply: My program provides lacrosse participation opportunities in which a majority of the participants or intended recipients are ethnic minorities. My program delivers at minimum an 8-week lacrosse program and works with our participants throughout the year. My program is committed to growing the game effectively and responsibly using US Lacrosse national standards and best practices. My program is a nonprofit organizations with a 501(c)(3) designation. My program can provide adequate field equipment for a traditional clinic or practice (Minimum 30 balls, two goal cages with complete nets etc.) My program can provide field space and proper field lines that meets US Lacrosse Rules and Guidelines for this clinic. My program can provide at least three program volunteers or coaches on site that can assist USL staff and Sankofa Lacrosse clinicians with drills and general clinic oversight. My participants have the proper equipment necessary to participate in a traditional lacrosse clinic. (See USL Equipment Fitting Guide for more information.) My program can provide signed waivers from all participants before the start of the clinic. My program can provide a roster of all clinic attendees prior to the clinic. My program can provide proof of insurance prior to the clinic. My program can host a weekend clinic. (Saturdays and Sundays only)
Describe specifically the impact that a USL-Sankofa Lacrosse Clinic would have on your program. Provide a brief statement about the current organizational needs to be addressed and geographic area to be served. Describe the mission, goals, history and accomplishments of your organization.
What impact does your program have on your local community? Provide any unique aspects of your program Provide the number of participants by gender, age, and ethnic group using the chart below (feel free to reproduce the chart if necessary): Boys Players Age: African-American Asian-American Hispanic/Latino Native American/Alaska Native Pacific Islander/ Native Hawaiian Caucasian Total: 10 and under 11-14 15-18 10 and under Girls 10-14 15-18
OBJECTIVE DATA: How long has your program been in existence? Just started 1-2 years 3-4 years 5+ years What is your program s annual operating budget? $0-$7,000 $8,000-$15,000 $16,000-$25,000 $26,000-$33,000 $34,000-$45,000 $50,000+ Total number of expected participants 0-25 30-60 70-100 Number of current full-time or part-time staff None 1-2 staff 3-4 staff 5+ staff 1-2 volunteers 3-4 volunteers 5+ volunteers Number of volunteers coaches None What percentage of your participants qualify for the National Free and Reduced Lunch Program 0-20% 30-50% 60-80% 90-100% How many of your players meet the National Poverty Standards? 0-20% 30-50% 60-80% 90-100% $100-$200 $500+ What is the cost for your program s participation fees? $0 $300-$400
Please provide your program s IRS Identification Number: If no, have you applied for 501(C)3 Status? Yes No Is your organization associated with an existing 501(C)3 Program Yes No I authorize the verification of the information listed above. I certify that the information contained in this application is accurate. I understand that false information may be grounds for not offering a clinic or termination of a clinic offering at any point in the future. By signing the certification you are attesting to the truth of the information you have included on this application. Program Director Name: Date: Program Director Signature: Send the completed application form to: US Lacrosse Attn: Senior Manager of Diversity and Inclusion 2 Loveton Circle Sparks, MD 21152 Fax 410-366-6735 diversityprograms@uslacrosse.org