Flexible Funding Form

Important things to know about Flexible Funding

Once a request is received, it will be forwarded to the AOC Flexible Fund Committee. The committee is made up of representatives from the agencies that have contributed to the fund. You will receive a notice whether it has been approved or not.

! The application must be completed by a service professional - someone who is working personally with the intended recipient of the fund.

! All funding requests are paid directly to vendors of goods and services and will not be distributed directly to the applicant.

Sponsoring Agency

Requested by (your name)

Phone Number

Email

Name of person who will be receiving service

Amount requested $

Criteria (check all that apply)

yes	Youth is 21 years of age or younger.
no

yes	Youth resides in Sitka
no

yes	Funding IS NOT for fees or services that are routinely provided by an organization or agency in Sitka.
no

yes	Funding request is a last resort. Youth and/or their families have sought assistance from other programs or organizations within Sitka. They have made an effort to provide some portion of the funds needed on their own.
no

yes	Funds are not for court or legal fees, or related court orders, assessments, classes, etc.
no

yes	Funds are not for in-patient or outpatient fees at a medical hospital or treatment facility.
no

yes	School activity requests have gone through the school's counseling office first.
no

yes	There are no OTHER current community resources to provide this service.
no

Summary of service to be provided:

Summary of efforts to provide this service from other resources:

List prior Flexible Funding requests for this person:

Please check any services used this past year:

School counseling services

Office of Children's Services

SEARHC Clinic II or other SEARHC services

SAFV (Sitkans Against Family Violence) Shelter

Public Assistance

SCPS (Sitka Counseling and Prevention Services)

Center for Community

STA (Sitka Tribe of Alaska)

Youth Advocates of Sitka

Salvation Army

Faith community social services

Other