Application Checklist Document Yes N/A WIC Local Agency Information (Page 2)

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1 Certification of Application All documents are required unless not applicable to your agency. Place a check in the Yes column if the document is complete and is being submitted with your application. If an item does not pertain to your agency, place a check in the N/A column. Application Checklist Document Yes N/A WIC Local Agency Information (Page 2) WIC Staffing Plan (Page 3) Organizational Chart Potentially Eligible and Client Services (Page 4) Outreach Plan and Public Notification (Page 5) Fit WIC Classes (Page 6) Nutrition and Breastfeeding Plan Staff Training Plans Budget Indirect Cost Agreement Budget Narrative Two copies of signed WIC Memorandum of Agreement with Attachments A through C Note: Att A is Page 4 of this application Certification Regarding Lobbying (not required for Tribes) Certificate(s) of Insurance (as per MOA) I,, the undersigned, hereby affirm the following: The statements contained in the funding application and all supporting documents are true and complete, to the best of my knowledge. The WIC Local Agency will comply with applicable ITCA and federal requirements, policies, standards, instructions, and regulations; I certify that I have the authority to apply for WIC funds for: Name of Organization Signature Date Printed Name Date ITCA WIC Application FY 2013 Page 1

2 WIC Local Agency s Legal Name WIC Local Agency Information Federal Employers ID# Type of Organization Tribe/Agency Administrative Mailing Address Tribe Private Non-profit Number and Street or PO Box DUNS # CFDA # WIC Main Clinic Street Address (provide description if no street address is available) WIC Clinic Mailing Address (if different) Number and Street or intersection/description Number and Street or PO Box WIC Clinic UPS/Fed Ex Shipping Address (if different) Number and Street or intersection/description Primary Contact (person responsible for dayto-day functions) Name Phone Fax Certifying Signature (person who can legally bind the WIC local agency and certify the funding application) Name Title ITCA WIC Application FY 2013 Page 2

3 WIC Staffing Plan *Identify at least one person for the following positions: Breastfeeding Lead & Registered Dietitian Attach an organizational chart for WIC including how WIC fits in with the overall organization. This may be two separate charts. Staff Name and Title Languages Spoken % WIC Time Select one of the following: Nutrition Services Oversight and High Risk Counseling The local agency selects the option for an ITCA designated Registered Dietitian to oversee nutrition services and provide high-risk counseling. The agency understands that if it serves more than 250 clients, an adjustment in funding will be made to provide these services as dictated in the funding formula for the fiscal year. The local agency chooses to oversee nutrition services and provide high-risk counseling using the following Registered Dietitian:. If the RD is not a part of the WIC staff, describe how the program will be coordinating with the RD to ensure that nutrition services have adequate oversight. ITCA WIC Application FY 2013 Page 3

4 Potentially Eligible and Client Services (Attachment A to MOA) 1. Describe the geographic service area and population that you will be serving below using geographical boundaries such as reservations, counties, cities or other easily discernible boundaries. Identify any special populations that the agency will target (American Indians, homeless, migrants, etc). 2. Fill in the clinic locations and schedule for all sites providing services. Clinic Locations and Hours Clinic Name Clinic Location Description Clinic Days Clinic Hours 3. Complete the table below for your caseload request for FY Category March 2012 Participation Pregnant Women Breastfeeding Women Postpartum Women Total Women Infants Children Total Potentially Eligible FY 2013 Caseload Request ITCA WIC Application FY 2013 Page 4

5 Outreach and Public Notification 1. Describe in detail how the agency will notify the public of the WIC services provided. At a minimum, the agency is required to notify the public of services on time per year. 2. Describe how you will target benefits to each of the following special populations: pregnant women, migrants, homeless persons and persons residing in group homes or other institutions. If one or more of these populations do not reside in your service area, indicate that in the description. 3. Complete the Outreach Plan below for the coming year describing how your agency will outreach both directly to clients and indirectly through referral agencies and grass roots organizations. All outreach must be documented in the Outreach Log. Name of Entity/Program/Event Frequency/Timeframe for Outreach Describe the outreach activity and the expected outcome ITCA WIC Application FY 2013 Page 5

6 Fit WIC Classes Describe the Fit WIC classes to be provided by the local agency. Class Schedule (i.e. every Thursday AM) Number of Classes to be offered per month Class Names (list names of all Fit WIC classes that are planned for the year including Fit WIC classes included as part of your Nutrition Plan) Class Facilitators Fit WIC Classes Average Number of Clients/Class Class Locations The local agency confirms that it will follow the guidelines for the Fit WIC classes as outlined in the Fit WIC Manual. The local agency will follow the guidelines for the Fit WIC classes as outlined in the Fit WIC Manual or the RD will create classes following the general structure of the Fit WIC classes on topics relevant to the population. Note: Course outlines must be available for review during monitoring visits. Not Applicable. The local agency does not choose to provide Fit WIC Classes. ITCA WIC Application FY 2013 Page 6