Free wisconsin abstinence initiative for youth club application, dph 40078 - Wisconsin


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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40078 (02/05)

STATE OF WISCONSIN Bureau of Community Health Promotion Direct questions to: 608-261-7654

WISCONSIN ABSTINENCE INITIATIVE FOR YOUTH CLUB APPLICATION
Completion of this form is required for inclusion in the WAIY Club Network under the provisions of OMB Circular A-110.51. INSTRUCTIONS: This application is to be completed by organizations wishing to sponsor a club in the Wisconsin Abstinence Initiative for Youth Club (WAIY) Network, a program of the Department of Health and Family Services.

SECTION 1 - WAIY CLUB IDENTIFICATION INFORMATION
Key Contact for Club Sponsoring Organization Name Mailing Address Title within Organization Telephone Email Club Advisor(s) Name, Address, and Telephone if Different from or Additional to Key Contact Fax

City and Zip Code Key Contact's Role School Contact Club Advisor Fiscal Administrator for Club Region Regional Coordinator

Fiscal Agency Name and Address if Different from Sponsoring Organization Fiscal Agency Representative Name and Title Telephone Email Address

SECTION 2 - SPONSOR AGREEMENT, FISCAL AND BACKGROUND INFORMATION, AND SIGNATURE
The Agency Representative agrees to accomplish the following goals: Promote abstinence among unmarried youth aged 19 and younger in the community Hold monthly discussions to explore WAIY's eight topics for healthy relationships Hold a minimum of one activity per month for club members Submit the WAIY Club annual report The State of Wisconsin Taxpayer Identification Number Verification Form (DOA-6448) is signed and attached I order to receive funds (download form DOA-6448 at http://www.doa.state.wi.us/docs_view2.asp?docid=704). A copy of the sponsoring organization's policy and procedure for conducting background checks on adults working with youth as advisors or volunteers in the organization is attached. If unable to do so, please explain on the reverse side.

Name of Authorized Agency Representative SIGNATURE - Authorized Agency Representative

Title Date Signed

Submit completed form with attachments to: Abstinence Program Consultant Department of Health and Family Services Division of Public Health, Room 351 P.O. Box 2659 One West Wilson Street Madison WI 53701-2659