US LACROSSE URBAN LACROSSE ALLIANCE PROGRAM 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 selected as an USL Urban Lacrosse Alliance Affiliate what benifits package would you select? (Your selection has no bearing on acceptance into the program. This information helps us to plan and allocate resources accordingly.) Package A - Up to 30 Men s or Women s lacrosse sticks and subsidized cost of officials fees (up to $1,500) Package B- Team uniforms and cleats for up to 25 players and US Lacrosse Convention registration and travel stipend for up to two coaches (limit $350 per coach) Package C- Subsidized league or tournament registration fees (up to$1,500) and one case of NOCSAE lacrosse balls w/bag and two lacrosse goal nets Package D -Subsidized field rental OR transportation costs (up to $1,500) and up to 25 team helmets or goggles. Please indicate if you have applied for or intend to apply for the National Diversity Grant Program Please indicate if you have applied for or intend to apply for the USL First Stick Program
Describe specifically how the Urban Lacrosse Alliance Program will make an impact on your program. Provide a brief statement about the current organizational needs to be addressed and geographic area to be served. Provide specific and detailed description of the project, its aims, objectives and method of implementation. Describe the mission, goals, history and accomplishments of your organization.
Briefly list and summarize any additional, non-lacrosse program services you offer, if any. (e.g., counseling, mentoring, nutrition) Do you host clinics and camps? How many clinics and/or camps will your program host this year? Please provide details What impact does (or will) your program have on your local community? Provide any unique aspects of your program
Provide a detailed description of a typical day of training in your program, including details of conditioning, time for drills, time for competitive play, time for instruction on things other than lacrosse etc. Please attach additional page(s) or calendar schedule if needed. *If you do not currently have a program, please provide a detailed description of your plans for your program and what on-field guidelines you intend to implement. Provide the number of participants by gender, age, and ethnic group using the chart below Boys Players Age: AfricanAmerican 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 11-14 15-18
Please describe your approach to financing and fundraising for your organization s development (you may include a proposed budget.) Explain how the success or effectiveness of the program will be measured. OBJECTIVE DATA: 1. How long has your program been in existence? Just started 1-2 years 3-4 years 5+ years 2. What is your program s annual operating budget? $0-$7,000 $26,000-$33,000 $8,000-$15,000 $16,000-$25,000 $34,000-$45,000 $50,000+ 3. Total number of expected participants this season 0-25 100-150 225-275 50-75 175-200 300+
4. Numbers of days per week regular (2 or more times a week) participants in your program have set practice 1-2 days 3-4 days 5-7 days 5. Number of months per year you offer participation opportunities 1-3 months 4-6 months 7-9 months 10-12 months 6. Number of months per year you have contact with your participants 1-3 months 4-6 months 7-9 months 10-12 months 7. Number of current program full-time staff none 1-2 full-time staff 3-4 full-time staff 5+ full-time staff 3-4 part-time staff 5+ part-time staff 3-4 volunteers 5+ volunteers 8. Number of current program part-time staff none 1-2 part-time staff 9. Number of volunteers coaches none 1-2 volunteers 10. What percentage of your participants qualify for the National Free and Reduced Lunch Program 0-20% 30-50% 60-80% 90-100% 11. What percentage of your participants have a mental or physical disability? 0-20% 30-50% 60-80% 90-100% 12. How many of your players meet the National Poverty Standards? 0-20% 30-50% 60-80% 90-100%
13. What is the cost for your program s participation fees? $0 $300-$400 $100-$200 $500+ 14. Does your organization have 501(C)3 Status? 15. Please provide your program s IRS Identification Number: 16. If no, have you applied for 501(C)3 Status? 17. Is your organization associated with an existing 501(C)3 Program? 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 grant or termination of a grant 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: Program Director Signature: Send the completed ULA Application Form to: US Lacrosse Attn: Senior Manager of Diversity and Inclusion 2 Loveton Circle Sparks, MD 21152 Fax 410366-6735 diversityprograms@uslacrosse.org Date: